Cluster Evaluation of Health Infrastructure Support for First Nations and Inuit

Indigenous Peoples face Insufficient Quality and Quantity of Housing

Canadians are currently facing a severe shortage of affordable housing, with housing demand significantly increasing from 2016 to present, while housing supply has not maintained the same pace.^{Footnote 21} As of 2021, 35.7% of First Nations living on reserve and 52.9% of Inuit living in Inuit Nunangat live in unsuitable and inadequate^{Footnote 22} housing.^{Footnote 23}

56% of First Nations Representatives engaged in this evaluation specifically highlighted the impact that the acute shortage of housing has had on the health of First Nations, and the ability of health care workers to provide adequate care. The lack of housing availability, adequacy, and suitability impacts health, including health conditions (e.g., mould leading to asthma), increased spread of viral diseases due to overcrowding (e.g., as during the COVID-19 pandemic), and even leads to increased gender-based violence.^{Footnote 24} According to key informants, the lack of housing availability has also impacted communities' and health centres' abilities to recruit and retain health care staff as they are unable to offer temporary and stable housing in the community. As such, when Indigenous peoples seek education in health care professions, they are often required to leave the community to access employment opportunities and training. This further exacerbates existing challenges in the recruitment and retention of qualified health professionals in community to provide culturally safe and accessible care to remote or rural Indigenous patients.

Indigenous Peoples face heightened rates of Economic Adversity

The economic status^{Footnote 25} of any individual has a significant impact on their ability to maintain their health and access services when needed. Notwithstanding the direct link economic status has to one's ability to access other key social determinants of health (i.e., ability to afford housing, food, and/or education) which impacts health status, it also directly affects an individual's ability to afford services that are not covered by provincial or territorial health insurance.

Indigenous peoples throughout Canada face higher rates of economic adversity.^{Footnote 26} First Nations and Inuit contend with barriers including higher cost of living (particularly in remote and rural areas), lower opportunity for employment, and lower comparative incomes.^{Footnote 27} Living in poverty has strong ties to substance use and increased violence in communities, which in turn impact both the physical and mental health of those residing within these communities, resulting in greater need for emergency services and mental health support programs.

Indigenous Peoples continued to face Social Exclusion, Anti-Indigenous Racism, and Discrimination

Social Inclusion

Experts categorize social inclusion as a determinant of health, as research shows that social exclusion can negatively impact both access to care and mental health and wellness.^{Footnote 28} Social exclusion is a result of social inequities, typically dictated by the way certain populations are marginalized and systemically excluded through social and economic policies and systems. Canada has acknowledged that Indigenous peoples are among four populations of people who have been denied equitable access to social services, including health, housing, and education.^{Footnote 29} To support addressing the social determinants of health, social prescribing was introduced to with the goal to increase collaboration between clients, staff and community providers to develop solutions. Social prescribing intends to function as a tool to complement medical care.^{Footnote 30}

Anti-Indigenous Racism

Anti-Indigenous racism refers to racism directed specifically to Indigenous individuals. According to interviews, anti-Indigenous racism has both direct and indirect impacts on the health of people in First Nations and Inuit communities. Indigenous peoples have long been subjected to discrimination and poor treatment due to the deep-rooted and severely harmful assumptions and negative stereotypes that are directed at them. The federal government acknowledges that Indigenous peoples in Canada continue to face racism and discrimination in the healthcare system.^{Footnote 31} For example, a common stereotype is that Indigenous people experience substance addiction challenges (i.e., alcohol and drugs), and as a result, Indigenous patients are often dismissed or ignored when they seek medical help with symptoms assumed to be alcohol or drug-related. In many cases, Indigenous peoples face violent and hateful treatment in the health care system, leading to increased trauma, dismissal of medical challenges by health care professionals, and fear of seeking care.

According to research conducted and shared by a First Nation subject matter expert (SME), the trauma of colonialism and continued racism faced by Indigenous peoples have intergenerational repercussions that manifest through higher likelihood of physical maladies. Countless instances of abuse and mistreatment of Indigenous peoples within the health care system have resulted in preventable fatalities. Interviewees noted the need for prioritizing the recruitment and retention of human resources who are equipped to provide culturally safe care and support Indigenous peoples accessing safe and traditional medical practices and healing.

Further to physical health impediments, research has shown racism and discrimination can cause intense stress and trauma in victims.^{Footnote 32} These conditions are often linked to deeper mental illnesses (i.e., anxiety, depression) and can even cause addictions to alcohol or drugs.

As such, a significant number of interviews (29%), particularly among First Nations Representatives (67%) and Implementing Partners (60%), highlighted the need for trauma-informed, culturally sensitive health care services, citing racism and discrimination as a major barrier to health care for Indigenous peoples nationwide.

Indigenous Women and Girls

While being a member of any one designated group (e.g., women, persons with disabilities, racialized groups, etc.) already creates numerous barriers, the challenge becomes even greater when considering the impacts of intersectional identities^{Footnote 33}. When assessing the impact of Indigeneity on access to health services, it is important to consider the unique challenges faced by Indigenous people who also identify as members of other designated groups. In particular, Indigenous women were highlighted by interviewees as a group that experiences challenges that differ from both Indigenous men and non-Indigenous women.

Before colonization, many Indigenous women and girls held positions of leadership and decision-making in their respective populations, which were significantly harmed by forcible alteration of matrilineal practices and the denial of rights for Indigenous women under the Indian Act. The National Inquiry into Murdered and Missing Indigenous Women and Girls (MMIWG) notes that Indigenous women and girls are almost twice as likely to face violence than non-Indigenous women, with almost six in every ten Indigenous women and just over three in every ten non-Indigenous women having experienced physical assault^{Footnote 34Footnote 35} Furthermore, it is imperative to consider the additional health services required for people with uteruses. Indigenous women and girls, those identifying as two spirit, women, gender fluid, or non-binary with uteruses have additional health needs which may include pregnancy and childbirth.

Chronic Illnesses and Multi-Morbidities

Throughout interviews, partners discussed the medical conditions and illnesses that were most prevalent for First Nations and Inuit. The heightened incidence of chronic illness and multi-morbidities among Indigenous peoples is added to by literature.

Chronic Conditions

A significant number of First Nations respondents (33%) noted that obesity, cancer, diabetes, and other chronic illness continuously impacted the overall health and wellness of First Nations and Inuit. More specifically, several partners noted diabetes as a core health need, with statistics validating that Indigenous populations are diagnosed with diabetes earlier in life, with more severe symptoms at the time of diagnosis, and also experience higher rates of complications and worse treatment outcomes than non-Indigenous Canadians.^{Footnote 36} The increased prevalence of diabetes among First Nations and Inuit results in greater need for appropriate staff and equipment to support with preventative care and treatment, and education initiatives in Indigenous populations. Further, the symptoms of diabetes can increase the need for other specialists (i.e., for foot care treatment).

Self-reported rates of long-term chronic health conditions and their prevalence among Indigenous populations are outlined below:

Communicable Diseases

A select number of interviewees (7%) noted sexually transmitted infections (STIs) and tuberculosis as additional core health issues experienced by First Nations and Inuit within their communities. In the case of tuberculosis, it was noted that the housing shortage and lack of capacity to support isolation of contagious patients results in increased numbers of the disease among First Nations and Inuit in their communities.

Mental Health and Wellness

Trauma

Traumatic experiences and intergenerational trauma are linked to mental health challenges in First Nations and Inuit populations. Historically and to this day, Indigenous peoples have endured trauma from a number of sources, which include but are not limited to colonialism, residential schools, forcible removal of children from their families, racism and discrimination. In addition, Missing and Murdered Indigenous Women, Girls, and Two-Spirit People, and the persistent impacts of residential schools are all examples provided by interviewees as traumatic events that continue to exacerbate mental health challenges for themselves and people in their communities. According to the Calgary-based Mental Health Literacy Organization, mental health challenges are also linked to substance use challenge and suicide.^{Footnote 41}

Substance Use & Addiction

Interviewees noted particularly acute challenges with alcohol and drug dependencies faced by First Nations and Inuit throughout Canada. Socioeconomic factors, including poverty, homelessness, and lack of access to social services and education are known contributors to substance dependence and addiction struggles. Literature also notes the impact of substance use and addition on exacerbation of homelessness, poverty, and barriers to access to social services.^{Footnote 42}

Suicide

Statistics illustrate that youth suicide rates are higher among Indigenous youth than non-Indigenous youth in Canada. Suicide rates for First Nations people are three times higher than that of non-Indigenous people at 24.3 deaths per 100,000 person-years at risk.^{Footnote 43} The rates of youth suicide among Inuit is nine times higher than that of non-Indigenous people, at 72.3 deaths per 100,000 person-years at risk.^{Footnote 44}

Community-Based Care

Due to the rural and/or remote nature of many Indigenous communities, the nearest health care center for First Nations and Inuit is often not close to their home. The lack of community-based care can, therefore, be the difference between life and death when seeking treatment for health-related issues. This is even more difficult where ambulatory services or transport treatment is unavailable, or in some instances as shared by interviewees, provision of service is refused near reserve communities.

Regional Specific Needs

Interviewees and literature review also note the unique needs faced in urban, rural and remote, and Northern communities. In urban settings, Indigenous peoples often experience a lack of cultural sensitivity when interacting with health care workers, as well as an overall lack of healthcare capacity and funding for health care services. In rural, remote, and Northern communities, there are increased difficulties with recruiting and retaining health care staff. In Northern communities the unique climate can cause limited or obstructed access to community by road (where road access exists), creating interrelated challenges of recruiting and retaining health care staff, climate impacts can result in a higher probability of certain medical conditions (e.g., respiratory and cardiovascular illness)^{Footnote 46} manifesting as well as increase challenges in housing or health facility construction and maintenance.

In order to ensure timely access to care, it is vital that people in communities have adequate and suitable facilities within the community, with the functioning equipment to provide health services.

According to interviews, many communities lack the physical space to operate facilities that support the level of health service delivery required, with some noting that their only option was to operate health services in closets or church basements. It was noted that some communities continue to not have access to clean water^{Footnote 47}, a necessity for an appropriate health facility.^{Footnote 48} In one Focus Group, it was noted that over 80% of one region's health facilities inventory had not been renovated/repaired since 2000, highlighting the need for renovations and repairs to maintain adequate facilities in which to provide care. The outdated nature of many of these buildings create additional challenges when attempting to outfit facilities with the necessary technology to operate effectively in the current society.

Furthermore, it was highlighted in interviews that facilities are not always equipped to allow for traditional and cultural practices, either as a result of limited financial and resource capacity or actual barriers in the physical infrastructure of the buildings (i.e., Heating, Ventilation, and Air Conditioning (HVAC) system for smudging^{Footnote 49}), which sometimes relates to adhering to codes and/or standards in building construction and/or operation. When considering the adequacy and suitability of community-based health facilities, it is important to consider what the specific needs of the patients in that area are, and in the case of Indigenous communities, access to traditional medicine is a core need. One of the key challenges Indigenous peoples have faced is erasure of their culture and traditions, and an imposition of assimilation to western practices. For health facilities to truly meet the needs of the Indigenous communities, they must reflect community needs and values.

Community-Based Health Care Workers

In order to provide adequate and timely care, community health facilities require an appropriate level of staff. Most interviewees (58%) noted that there is a shortage of health care workers and limited health care capacity in communities. Partners noted an acute need for additional community-based workers to deliver health services and emphasized in these discussions that there have been ongoing challenges with recruiting and retaining health care staff in communities. These challenges include a lack of funding to allocate to salaries and benefits, a lack of interest from staff in remaining in-community (due to working conditions), and a lack of housing capacity to provide shelter for external health care workers. The lack of accommodation for health care workers in Northern regions was specifically noted as a key issue in one focus group. Interviewees highlighted a need for early education opportunities to encourage and support Indigenous youth to pursue careers in healthcare to support sustainable measures to overcome these continuous staffing shortages.

Appropriate Training & Expertise for Community

Most interviewees (55%) noted a specific gap in having access to health care workers with appropriate expertise, training, and cultural sensitivity. A select number of SMEs who participated in interviews recounted the challenges in hiring nursing staff, and how in their absence, communities have worked to train paramedics to ensure that they have the basic capabilities to treat patients in community rather than sending them to the provincial health center. In addition, due to the lack of training provided, even when staff have the appropriate tools, they would likely not be able to use them. Program partners also noted that community health directors have voiced the need to improve skillsets to support Licensed Practical Nurses (LPN), including training for various fields, including therapy, registered massage therapy (RMT), acupuncture, reflexology, dental hygiene, and child and youth counselling. It was emphasized that while there is great need for frontline health care workers, such as nurses and doctors, there is also need for support workers, including nursing informatics and digital technicians, particularly as the demand for remote, digital health services grows. Due to the distance between provincial health facilities and communities, there is often a need for speciality doctors (e.g., oncologists, endocrinologists) in community that continuously remains unmet.

Further, the need, and current lack of, culturally trained health practitioners was a key trend in interviews. A significant number of First Nations Representatives (44%) and SMEs (50%) noted that racism and discrimination in the healthcare system remains an ongoing issue. Given this, as well as trauma endured in the healthcare system, First Nations and Inuit patients require services delivered by individuals trained in cultural humility. Ideally, community-based staff would be members of the Indigenous community and would therefore have the necessary understanding of cultural sensitivities. Moreover, First Nations and Inuit patients require health services professionals who practice two-eyed seeing when providing care, including the strengths of both culturally-specific medicine and western medicine.

Technological Infrastructure^{Footnote 50}

In today's technology-fueled society, particularly in the post-pandemic environment, having virtual access to health care services is vital. As such, the electronic infrastructure in communities is key to their ability to access, and professional's ability to provide, digital care. Throughout interviews with both internal and external partners, connectivity was highlighted as a key ongoing challenge for First Nations and Inuit communities in a significant number (25%) of discussions. Specifically, it was noted by First Nations Representatives and Implementing Partners that even when the required technology is implemented and deployed, the communities are challenged to connect to the required networks. Given the numerous barriers to accessing health services in person (further explored throughout this report), communities require the capability to communicate with health professionals virtually through reliable networks. The absence of this can result in patients not receiving timely, life-saving care.

Additionally, the health facilities located in communities need to be able to electronically communicate with each other. Appropriate health care requires a complete understanding of a patient's medical history. This data is typically shared among health care practitioners through the patient's Electronic Medical Record (EMR).

From the perspective of community members seeking care, connectivity is required to connect with health professionals, regardless of physical residence. From the perspective of health practitioners within the communities, connectivity is required to conduct daily operational activities efficiently, monitor and store patient data, and perform medical procedures. It was specifically noted by one First Nations Representative that many health centers in communities still use paper systems, and as a result, they are inefficient and exposed to critical patient safety issues. If medical data is illegible or misplaced, this can result in very serious consequences for the impacted patients. With already such limited capacity and resources in the health centres, inefficiencies result in time taken away from being able to attend to patient needs.

Maintenance

Another key challenge highlighted by partners was the level of maintenance required to keep technological equipment up to date. Technology is rapidly evolving and as such, hardware and software often require regular updates. The pace at which e-infrastructure investments are evolving is not matching the evolution of technology, meaning that even where communities have access to technology, it is often outdated. Further, there is a need for properly trained staff with the ability to operate the technology, and support with education initiatives, support evolving technologies, and maintain hardware, as needed.

Data Management and Sovereignty

Under the umbrella of the identified need for Indigenous peoples to lead the direction of their own health services, the need for data sovereignty must be considered, particularly as it relates to health data management through digital health technologies such as electronic medical records (EMRs). This also considers the First Nations principles of Ownership, Control, Access, and Possession (OCAP^®), which asserts that First Nations alone should have control over data collection processes and how data is then stored, interpreted, used, or shared,^{Footnote 51} and the National Inuit Strategy on Research (NISR), outlining the five priorities to facilitate Inuit Nunangat research in an efficient, impactful, and meaning manner.

The movement of health data is vital to patient health, as is the integrity of the privacy around health data. As such, it is important for Indigenous communities to control the level of access others have to their data. A significant number of First Nations Representatives (22%) and Implementing Partners (20%) noted the need for data sovereignty and governance as it relates to OCAP^® principles.

Further, from an efficiency perspective, interviewees noted the need to ensure appropriate data management and sharing practices are in place to ensure health practitioners have access to the data they need to provide adequate care.

Health Care Services Continuum

The highest quality health care is continuous, proactive, and comprehensive. Health services should exist on a continuum, with consideration given to preventative, emergency, and aftercare, as well as access to related or complementary health services.

Promotion and Prevention Care

As a result of the many barriers to access health services, it is highly common for First Nations and Inuit to fall ill to more severe conditions or in some instances, succumb to preventable diseases. According to interviews, this is directly linked to an absence of appropriate health care promotion and early prevention care in communities. Health promotion initiatives work to communicate the value of healthy practices, in many areas, including mental health and wellness, as well as education and identification of indicators of specific conditions or illnesses. In order to avoid the continuation of challenges in the areas of mental health and substance use, interviewees noted that communities would benefit from increased ongoing and preventative programming that supports community members prior to reaching the point of requiring medical attention.

Emergency Services

In addition to the gaps identified in prevention and after care, interviews also indicated a need to improve access to emergency services. This was noted in relation to a lack of appropriate emergency transportation, such as ambulances or helicopter evacuation options, for remote communities. In a health emergency, response time can heavily impact prognosis and probability of survival, and the absence of accessible emergency services for remote communities can result in a higher rate of patient fatality.

Long-Term Care

Another theme that emerged throughout interviews was the need for enhanced long-term care in communities. While the Indigenous population of Canada is overall younger than non-Indigenous Canadians, the Indigenous population is projected to age faster, due to a shorter estimated life expectancy.^{Footnote 52} As the aging Indigenous population continues to grow, access to long-term care has become a greater challenge, yet health care funding is often not sufficient to include such areas of care. Elder populations tend to require more frequent and specific types of care, which leads to increased need for health care professionals with those skillsets, facilities that can accommodate patients, and appropriate funding to provide both. Furthermore, Indigenous peoples tend to favor aging-in-place^{Footnote 53}; however, this requires adequate levels of health professionals to provide live-in or home-visit medical care.

Cultural Safety and Humility

Cultural safety^{Footnote 54} and cultural humility^{Footnote 55} are vital to ensuring an equitable health care system. A culturally safe and humble environment requires an absence of racism and discrimination, and an understanding and respect of Indigenous cultures. This includes an integration of traditional and cultural practices in health services.

Traditional Practices

Indigenous cultures have traditional healing practices that differ from those commonly applied in western cultures. Traditional healing and wellness are defined by the FNHA as "health practices, approaches, knowledge and beliefs that incorporate First Nations healing and wellness".^{Footnote 56} These practices often incorporate the use of natural remedies, ceremonies, and energetic therapies.^{Footnote 57}

Partners emphasized that to provide genuinely effective, inclusive, and complete care to Indigenous populations, health services need to make space for traditional medical practices. While this was a gap noted by a significant number of interviewees (43%) in current health centres, some First Nations Representatives and Implementing Partners shared ways in which these practices have been incorporated in their community health centres, which has included Elders and Knowledge Keepers being onsite to encourage smudging and praying.

Impact of COVID-19

The pandemic exacerbated the existing social inequities that contribute to the barriers Indigenous peoples face in accessing high quality health care services. Economic challenges associated with lockdown measures impacted individuals financially, forced both temporary and permanent closures of businesses, closure of schools and childcare centres, and left many people struggling to balance caring for families, homeschooling children, and navigating the economy. The economic impact of COVID-19 pressured unemployment rates and increased the incidence of homelessness throughout Canada. Studies distinctly demonstrated disproportionate impacts to marginalized communities throughout the pandemic, Indigenous peoples being one of these populations.^{Footnote 58}

The measures implemented to reduce the spread of the virus resulted in a number of additional consequences to the health of First Nations and Inuit communities. Overcrowding made isolation mandates very challenging. 20% of interviewees recounted higher than average mental health and wellness needs during the pandemic, as well as an increase in number of individuals seeking support for substance use and addiction.

Positive Outcomes

Interviewees (ISC staff as well as First Nations Representatives and Implementing Partners) noted that there were positive outcomes or best practices that could be taken from the COVID-19 pandemic and applied in the future. These best practices focused on the flexibility in reporting requirements, the enhanced communication, and ease of transfer of funding. Many interviewees indicated that if these processes were as efficient on an ongoing basis as they were during COVID-19 response efforts that their relationships with ISC staff would be strengthened.

One key example provided by interviewees of a positive outcome of the COVID-19 pandemic was the support for the adoption of virtual care. As a result of lockdowns, mandatory quarantine, and the impact for the healthcare system to deliver services in-person (e.g., elective surgeries), much of healthcare pivoted to digital delivery which made care more accessible for some individuals. Program Leads and Implementing Partners noted an increase in demand for certain services, particularly the Quality Improvement and Accreditation program and connectivity for eHealth programming. Many interviewees also noted the positive impact that being accredited had on their organization, including emergency preparedness and crisis management planning that is part of the accreditation program.^{Footnote 59}

British Columbia Declaration on Cultural Safety and Humility

The CS&H was signed by the FNHA in 2015 as a commitment to advance cultural safety and humility within health organizations delivering services to Indigenous peoples.^{Footnote 60}

The Declaration is based on the following guiding principles of cultural safety and humility:

• Cultural humility builds mutual trust and respect and enables cultural safety;
• Cultural safety is defined by each individual client's health service experience;
• Cultural safety must be understood, embraced, and practiced at all levels of the health system including governance, health organizations and within individual professional practice.

Truly effective health care should make the patient feel safe, both from a medical competency and a cultural standpoint. In addition to interviews, this evaluation included a survey conducted with both internal and external partners^{Footnote 61} in order to capture insights from those unable to participate in interviews. This survey included a number of questions that specifically related to the alignment of the Cluster programs to the CS&H principles.

As described previously throughout the Relevance section of this report, the mistreatment of Indigenous peoples can often lead to either a lack of appropriate attention or treatment from health professionals or an avoidance of health facilities from Indigenous patients, which can ultimately result in delayed and misdiagnoses or preventable fatal illnesses.

Despite these identified gaps, survey data indicated that the majority of both internal (72%) and external (60%) partners agree or strongly agree that the Cluster program(s) they are involved with allow for wholistic support including the right to access cultural practices.

Text alternative for Figure 2 - The Cluster program(s) respect First Nations and Inuit values and rights, including right to access cultural ceremonies, practices, and supports

Figure 2 is a bar chart that illustrates survey results in response to the statement "The Cluster program(s) respect First Nations and Inuit values and rights, including right to access cultural ceremonies, practices, and supports". Responses were on a scale include Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, I don't know, and Not Applicable. Internal (to ISC) responses were Strongly Agree (28%), Agree (44%), Neutral (14%), Disagree (0%), Strongly Disagree (3%), I don't know (8%), and Not Applicable (3%). External (to ISC) responses were Strongly Agree (19%), Agree (41%), Neutral (19%), Disagree (19%), Strongly Disagree (0%), I don't know (4%), and Not Applicable (0%).

Source: Survey deployed by ISC Evaluation, 2022.

While the objectives of the programs align with these principles, there were several gaps shared throughout interviews, including a lack of appropriate training of staff on cultural humility (ISC internal staff and health centre staff) and a lack of consideration of traditional medicine practices in infrastructure of health facilities that indicate room for improved integration in execution. It was highlighted in interviews that the need for cultural humility is required in all roles, including those that do not operate directly with patients. This includes roles internal to ISC, as well as those in implementing partner institutions who play a role in defining program objectives/parameters and developing resources and frameworks within which communities operate health services.

The survey also asked if respondents felt as though there was an established culture of accountability to advance anti-racism and cultural safety and humility in their respective organizations, to which the majority of both internal (66%) and external (52%) partners agreed.

Text alternative for Figure 3 - There is an established culture of accountability to advance anti-racism and cultural safety and humility in my organization

Figure 3 is a bar chart that illustrates survey results in response to the statement "There is an established culture of accountability to advance anti-racism and cultural safety and humility in my organization". Responses were on a scale include Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, I don't know, and Not Applicable. Internal (to ISC) responses were Strongly Agree (9%), Agree (66%), Neutral (20%), Disagree (3%), Strongly Disagree (3%), I don't know (0%), and Not Applicable (0%). External (to ISC) responses were Strongly Agree (15%), Agree (52%), Neutral (15%), Disagree (3%), Strongly Disagree (3%), I don't know (0%), and Not Applicable (0%).

Source: Survey deployed by ISC Evaluation, 2022.

Additionally, approximately half of internal (49%) and external (52%) respondents responded "Agree" in response to a question asking if their respective organizations have processes to manage feedback or reports of harm on racism-related, quality and safety issues.

The data gathered in interviews and surveys suggest that while opportunities to improve the level of prioritization of cultural humility and patient safety in the design and delivery of health programs remain, Cluster program partners and communities have worked to apply these principles as much as capable within program restraints.

Canadian Patient Safety and Quality Framework

The Canadian Patient Safety and Quality Framework was developed in 2018 by the Health Standards Organization (HSO) and the Canadian Patient Safety Institute (CSPI) in order to align quality and safety improvement across Canada.^{Footnote 62}

The CPS&QF is guided by the following principles:

• Patient care is as safe as possible across the country, and efforts are made to prevent, respond to, and learn from a patient safety incident;
• Jurisdictions and organizations have mechanisms for measuring and monitoring safety;
• Patients, families, and the public are actively engaged and empowered;
• Supportive and engaged leadership promotes a culture of safety;
• A caring and just culture is established at all levels of Canadian health care; and
• The health workforce is engaged and supported.

When asked about perception of whether current services were safe and free from preventable harm, survey responses were more varied, with internal and external groups voting Agree (26% and 33%), Neutral (20% and 30%) and Disagree (23% and 19%), respectively.

Text alternative for Figure 4 - The Cluster programs allow for services that are safe and free from preventable harm

Figure 4 is a bar chart that illustrates survey results in response to the statement "The Cluster programs allow for services that are safe and free from preventable harm". Responses were on a scale and include Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, I don't know, and Not Applicable. Internal (to ISC) responses were Strongly Agree (9%), Agree (26%), Neutral (20%), Disagree (23%), Strongly Disagree (0%), I don't know (17%), and Not Applicable (6%). External (to ISC) responses were Strongly Agree (4%), Agree (33%), Neutral (30%), Disagree (19%), Strongly Disagree (4%), I don't know (7%), and Not Applicable (4%).

Source: Survey deployed by ISC Evaluation, 2022.

It was noted that the CPS framework is predominantly relevant to the QIAP, given the program's objective of improving quality of services. As part of the Accreditation program of one accrediting body, organizations are required to complete a Canadian Patient Survey tool used to build the culture of patient safety in their communities. Additionally, it was highlighted that the existing standards involve ensuring clients, patients, and families are involved in the development of the organization's priorities.

In response to a question asking if the Cluster programs could be improved for better patient safety and harm prevention, the majority of both internal (75%) and external (89%) respondents Agreed or Strongly Agreed.

Text alternative for Figure 5 - The Cluster programs could be improved for better patient safety and harm prevention

Figure 5 is a bar chart that illustrates survey results in response to the statement "The Cluster programs could be improved for better patient safety and harm prevention". Responses were on a scale and include Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, I don't know, and Not Applicable. Internal (to ISC) responses were Strongly Agree (26%), Agree (49%), Neutral (6%), Disagree (0%), Strongly Disagree (0%), I don't know (14%), and Not Applicable (6%). External (to ISC) responses were Strongly Agree (35%), Agree (54%), Neutral (4%), Disagree (0%)3, Strongly Disagree (0%), I don't know (4%), and Not Applicable (4%).

Source: Survey deployed by ISC Evaluation, 2022.

Interviews highlighted a number of gaps in patient safety in existing health services, and the majority of survey respondents strongly agreed (26% of internal respondents and 35% of external respondents) or agreed (49% of internal respondents and 54% of external respondents) indicated that the Cluster could be improved for better patient safety and harm prevention.

While the CPS focuses on safety from a medical perspective, to be truly safe in health care facilities, Indigenous patients require services delivered by people and environments that also promote cultural safety.

Health Planning and Quality Management

The HPQM program aims to provide guidance to regions who work directly with First Nations and Inuit on creating health and wellness plans. Funding agreements are issued under the program to support the development and ongoing management of Multi-Year Work Plans and of Health and Wellness Plans. The program also supports improving health services and programming by incorporating quality improvement activities in health programs (e.g., accreditation and evaluation of health programs).

A key trend noted in interviews was the need for community-specific needs-based health planning and funding. Indigenous communities desire the autonomy to identify the needs of their community themselves and build programs that address those needs as they see fit. However, they also require the appropriate level of sustainable support to build the capacity to continue to conduct their own health planning in the long-term. Further, the need for improved quality of care, including access to health services in the appropriate facilities, with culturally and medically competent staff and the necessary equipment to provide adequate treatment was emphasized throughout stakeholder groups.

Interviewees noted that the HPQM program was one that related to many of the other Cluster programs, in that appropriate health planning requires consideration of the required health facilities, the technology infrastructure, accreditation processes, as well as the hiring and training of health care staff.

As such, the objectives of the HPQM are well aligned with the current health needs of First Nations and Inuit.

Quality Improvement and Accreditation

The program contributes to advancing the self-determination and capacity for health services in Indigenous communities that meet their needs to improve health outcomes. The program accomplishes this by facilitating the uptake of accreditation and recommending Quality Improvement activities to increase community-based health human resource capacity of First Nations and Inuit to design, manage, evaluate, and deliver health programs and services. The benefit and value of the accreditation program is outlined as improving alignment with provincial health care services, promoting community engagement in patient safety activities, contributing to improved health outcomes, and supporting First Nations and Inuit-led health systems. Recently, enhancements have added emphasis in addressing racism in health care and a focus on cultural safety.

The value of accreditation for Indigenous health facilities was noted repeatedly across interviews with various partners. In particular, interviews emphasized that accreditation was often a point of pride for community health facilities and is considered a building block on which many of the other Cluster programs can leverage to continue to build capacity in communities. Accreditation was described as crucial to ensuring provision of services is aligned to best practices. Specifically, the element of cultural safety being integrated into accreditation processes is highly aligned to the existing needs of Indigenous communities. Given these outlined challenges, the objectives of the QIAP are considered to be aligned to the health needs of the First Nations and Inuit communities.

Health Human Resources

The HHR^{Footnote 63} program was created to contribute to the strengthening of Indigenous communities' social services, including healthy living and child development, community care, kindergarten to post-secondary education services, familial support, and communicable disease prevention. The objective is to increase the number of First Nations, Inuit, and Métis practicing in healthcare, and to increase the number of qualified individuals working in healthcare delivery in First Nations and Inuit communities. The program is delivered through two streams: scholarships and bursaries for Indigenous students pursuing health careers, and training and certification for community-based workers and health managers to improve the quality and consistency of health care services in First Nations and Inuit communities.

Interviews demonstrated that the intent behind the HHR program is aligned with the needs of the communities, given the notable shortage of community-based workers and appropriate expertise and training, as well as the need for early education in health care professions for Indigenous students.

eHealth Infostructure

The objective of the eHealth program is to provide the "right information to the right people at the right time" to support First Nations and Inuit in being connected, informed, and healthier, and to enable front-line health care workers working in First Nations and Inuit communities to improve Indigenous peoples' health through eHealth programming. The goal of current activities is to increase access to eHealth technologies to enable First Nations, Inuit, and health care providers to use eHealth technologies for the delivery of health care services.

According to interviews, the objectives of the eHealth program are well aligned with the needs identified in interviews, including connectivity, remote access to care, and the provision of integrated services across the health care continuum. Moreover, eHealth is well aligned with the First Nations OCAP^® principles by facilitating communities' capacity to effectively collect, distribute, and retain health-related data as they see fit.

Health Facilities Program

The HFP aims to support the development and delivery of health programs and services through investments in health facilities infrastructure. This contributes to First Nations and Inuit in assuming greater control over their own health program and service design, governance, and delivery, including through the planning and management of infrastructure.

The program supports three main categories of activities in relation to health facilities: facilities operations and maintenance (e.g., rent, utilities, cleaning, routine maintenance, minor repairs); minor capital projects (e.g., minor repairs and renovations that cannot be addressed through existing operations and maintenance budgets, less complex projects); and major capital projects (e.g., more complex projects to build new, expand, or significantly renovate/repair health facilities).^{Footnote 64} However, the program and ISC as a department is not directly involved in the delivery of these First Nation capital activities.

As aforementioned, interview data demonstrated that the lack of accessible, adequate, and safe health facilities is a very prominent need across Indigenous communities. As such, a program such as the HFP dedicated to bridging that gap is aligned to the health needs of First Nations and Inuit.

Health Services Integration Fund

The Health Services Integration Fund (HSIF) supports collaborative planning and multi-year projects aimed at better meeting the healthcare needs of First Nations and Inuit by working with provincial and federal levels of government and creating partnerships to integrate federally and provincially/territorially funded health services in First Nations and Inuit communities; improving access to healthcare for First Nations and Inuit; and increasing the participation of First Nations and Inuit in health programming design, delivery, and program evaluation.

As such, in the HSIF program, particularly in its noted flexibility, is aligned to the identified need for health programming to be driven by community-specific needs, with greater collaboration and control granted to First Nations and Inuit communities.

BC Tripartite Relations Initiative

In 2011, the federal and provincial Ministers of Health and BC First Nations signed the BCT Tripartite Framework Agreement on First Nation Health Governance, which established a new province-wide FNHA to assume control over the design, management, and delivery / funding of federally funded First Nations health programs and services in BC. Since 2013, the FNHA has worked to transform how health care is delivered to First Nations in the province, including closer collaboration and integration with provincial health services.

Interviews with BCT representatives highlighted availability and access to safe and effective care in remote regions, including primary care, mental health and wellness, and culturally safe care as key health needs for the region. A number of interviewees also referred to the recently published In Plain Sight Report that summarized the findings of an Addressing Racism Review that was launched in response to allegations of racist, discriminatory, and inequitable behaviour in BC hospitals.^{Footnote 65} This report emphasized the need for cultural safety and humility in BC health facilities.

Interviews with key partners demonstrated a clear desire among Indigenous communities to assume control of health services in their communities. As such, the proven transfer of health services under the BCT Agreement is highly indicative of strong alignment between the program and the needs of communities.

Cluster of Health Infrastructure Support

It is important to note that while the assessment of the aggregate data indicates that the Cluster programs' objectives are each aligned with the health needs of people in First Nations and Inuit communities, the level of need in each of the areas varies in specific regions or communities. This is noteworthy as there could be needs in communities that are higher priority that are not being met by these programs, while funding is only being allocated to these specific areas.

One key trend noted amongst interviews was the emphasis placed on the unique needs of various communities and how this must be adequately considered in order to ensure true program alignment. For example, there are some communities who may struggle more in training community-based workers and therefore value HHR, while another community may have no issues with training and instead require more funding to put towards mental health and wellness programs for at-risk youth. This type of scenario was used in interviews to highlight the potential pitfalls associated with designing programs with such specific parameters and objectives, as opposed to more widely applicable health transformation funding that communities could allocate to core needs as they are identified.

Extent to Which Cluster Programs are Appropriate Mix to Achieve Service Transfer

This evaluation also assessed the programs through the lens of understanding whether the combination of these targeted initiatives (Cluster programs) make up the appropriate mix to achieve service transfer. In discussions with key program partners, there were varying perceptions shared.

While a number of partners perceived the programs as aligned in objectives and identified opportunities to increase collaboration, a select number of program partners identified their perceived misalignment, particularly, that any existing alignment is not being highlighted at the national level and instead only if regions take the initiative to link them. However, many of these same partners noted that there are certain programs (e.g., Accreditation, Health Planning) that connect many similar elements.

Ultimately, partners emphasized that true alignment to needs requires the basis of a shared objective of improved capacity and self-determination. For programs such as Accreditation, interviewees highlighted that it creates a foundation that facilitates capacity building in the other program target areas, such as eHealth and HHR.

The level of continued demand for funding under all programs evaluated indicate a high degree of relevance to the existing needs. However, the continued challenges faced by people in First Nations and Inuit communities despite receiving some funding through these programs highlights a gap in effectiveness. These challenges are detailed further in the following sections of this report.

Program Delivery and Administrative Processes

In interviews, Implementing Partners and Program Leads were asked to rate their perception of the effectiveness of program delivery for the programs they were involved with on a scale of one to five (Very Ineffective - Very Effective).

Text alternative for Figure 6 - Perception of Partners on Overall Effectiveness of Program Delivery

Figure 6 is a pie chart that illustrates the responses of Implementing Partners who participated in interviews on the overall effectiveness of the delivery of program(s) they interact with under this Cluster. Responses were on a scale and included Very Ineffective, Ineffective, Neutral, Effective, and Very Effective. Responses were Very Effective (20%), Effective (60%), Neutral (20%), Ineffective (0%), and Very Ineffective (0%).

Source: Interviews by ISC Evaluation, 2022-2023.

Generally, Implementing Partners and Program Leads found the delivery of Cluster programs to be effective, with all respondents describing delivery as either Neutral (20%), Effective (60%) or Very Effective (20%). However, it should be noted that this data encompasses Implementing Partners' experiences with any number of the six programs being evaluated, and as such, could include varying perspectives depending on the program. In order to ensure the key strengths and areas of potential improvements were adequately captured, a further qualitative assessment of the effectiveness of each individual program's delivery in consideration of their unique context is outlined in Findings #8 - #13. To provide additional contextual information, this Finding seeks to illustrate the common areas of strength as well as areas of improvement that were noted regarding the effectiveness of program delivery across all Cluster programs.

Working Well

As indicated in the above graph, Program Leads and Implementing Partners generally perceive that the delivery of Cluster programs is effective, with 29% of internal partners selecting Neutral, 43% selecting Effective and 29% selecting Very Effective. 100% of external partners selected Effective. Commentary about aspects that were working well included the following:

• Cluster programs have been effective in progressing towards their intended outcomes and objectives, despite challenges such as limited funding or human resources.
• The flexibility and efficient administration of the additional funding provided during COVID-19 was highlighted as a key success. Timely access to data and information about First Nations and the impact the pandemic had on First Nations also allowed the department to better allocate resources and make decisions more quickly.
• Efforts have been made to reduce the reporting burden on recipients. For example, HSIF has updated their progress report template in recent years by simplifying the amount and type of information required to ensure only the most crucial elements remain, while also providing open text space for recipients to include additional information about their projects as they see fit.

Needs Improvement

In interviews, certain partners shared their perception of key program elements, such as administrative processes, performance measurement, and communications. Of those who were asked, between 20%-30% of partners noted that the following aspects needed improvement:

• While there have been efforts made to reduce administrative burden on First Nations, it was noted that there are still opportunities to streamline some administrative processes, especially for First Nations who may access various streams of funding from ISC and may therefore be required to complete a significant amount of progress reporting.
• Performance measurement and reporting requirements are often misaligned to operational outcomes and First Nations and Inuit ways of knowing, creating barriers to collecting accurate and meaningful data and presents an incomplete reflection of progress.
• Roles and responsibilities between various partners (e.g., ISC Headquarters (HQ) and Regions, Regions and First Nations) are often ambiguous, creating confusion around expectations and priorities.
• A localized approach to prioritizing needs is necessary in order to adapt to the unique needs of varying regions.

Throughout both internal and external interviews, over 74% explicitly noted insufficient funding and almost 60% explicitly noted a lack of capacity as barriers to the achievement of the Cluster programs' ultimate objectives. The specific ways in which these barriers impact the program delivery of each program is noted in the following pages.

These areas of improvement are detailed further below and in other sections of this report in Findings #16, 17, 21, and 22.

Performance Measurement & Reporting

In order to assess effectiveness, the evaluation required access to program data, tracked through performance measurement frameworks and results reporting. This proved to be more challenging than anticipated, due to limitations in data collection from programs. An assessment of the effectiveness of the Cluster programs' respective performance measurement frameworks and resulting reporting highlighted significant barriers to assessing progress. As such, the following sections of the report are based on limited quantitative program data.

The Cluster programs have individual performance measurement frameworks that are designed to measure program progress towards immediate, intermediate, and ultimate outcomes. Each program has a PIP, where specific performance indicators are meant to be outlined with targets, baseline data points, as well as descriptions of rationale, measurement strategy and data sources. While each PIP outlines a number of program-specific indicators, the programs may only be required to publicly report on one unique indicator in ISC's annual Departmental Results Reports.

Those indicators, for each program in scope, that are required to be reported are outlined below:

Each program had different approaches to collecting and reporting results from Implementing Partners and program recipients; however, the program files received demonstrated significant gaps in reporting against program indicators.

Review of internal documentation demonstrated that HSIF and eHealth each have annual project report templates that are provided to recipients, detailing the expected contents to be included.^{Footnote 67} For QIAP and HHR, annual reports are developed by the programs' respective Implementing Partners (i.e., Accreditation Canada, Canadian Accreditation Council, and Indspire) which outline progress in that fiscal year. However, in all documentation received, there was notable inconsistencies in either the nature of the data being collected/reported or the availability of these figures on an annual basis. This created barriers in evaluating program performance against outlined program objectives. Furthermore, the review of program data received indicated a significant gap in data collected over the evaluation period across the Cluster programs. In many cases, data reported varied between fiscal years or recipient reports, or was simply not provided in its entirety.

Performance measurement was noted in interviews as an area to improve by over 40% of Program Leads, 29% of Regional Staff, and 33% of Regional Executives. According to interviews, the reporting requirements can be difficult to meet due to a misalignment between government expectations and the nature of community reporting, the latter of which is often more based in cultural values, community needs, and storytelling rather than outcome reports. This variance was noted to cause challenges for programs to illustrate the outcomes of the program in a format that the federal government expects. As such, the effort required to align community reporting to these standards was said to be burdensome to First Nations.

Interviewees noted that overall program delivery would benefit from engaging with First Nations and Inuit who may be experiencing challenges with reporting requirements and develop a more relational approach to improve the process rather than expect First Nations and Inuit to follow existing, often bureaucratic processes that can lead to inaccuracies and inefficiencies.

Historically, reporting was completed through a reporting template that captured output-based data. However, in discussions with internal partners, it was noted that there are efforts to shift away from output measuring due to the challenges presented for infrastructure programs, such as HFP, which operate primarily as a facilitator of health projects or initiatives rather than service providers seeking to achieve a set of outcomes. Further, it was noted that while performance measurement frameworks are in place, they are rarely leveraged as the identified performance indicators are not reported against consistently. Internal program partners highlighted that the indicators in place are often outdated or misaligned to the current intended outcomes of the programs and that many programs described performance measurement as challenging, due to notable data gaps (e.g., baseline data against which to measure progress), lack of First Nations and Inuit input in metrics, and a lack of capacity to apply the frameworks in a consistent manner.

It was also noted in a select number of interviews that expectations around reporting can be particularly difficult to manage as to not infringe on First Nations and Inuit data sovereignty and OCAP^® principles. As a result, gathering data and aggregating information to report on program progress has been a challenge for a number of regions.

Internal interviews highlighted that as services continue to be transferred, more performance measuring and reporting activities will fall to those in First Nations and Inuit communities rather than regions, rendering existing frameworks redundant. This further supports the identified need to further integrate First Nations and Inuit input and direction in the development of relevant indicators in consideration of current and future operating landscapes. The evaluation also noted that there are efforts underway, both internally within the Department and externally with partners such as the FNHMA, to mitigate the potential reporting burden.

Stream 1: Bursaries

A review of Indspire program data from Fiscal Year 2019-2020^{Footnote 88} indicates that bursaries were awarded to over 700 Indigenous recipients, 49% of whom were status First Nations recipients, 3% of whom were non-status First Nations recipients, 4% of whom were Inuit recipients, and 44% of whom were Métis recipients. The bursaries awarded in 2019-20 had a total value of $2,550,000.^{Footnote 89}

The HHR PIP outlined a target of over 650 bursaries awarded, which was surpassed in every year except Fiscal Year 2018-2019.^{Footnote 92} Over 3,725 bursaries were provided to Indigenous students in health-related fields since 2015.

Program data received from fiscal year 2017-2018 to 2019-2020 provided greater depth of insight into the recipient profiles of the HHR program, as well as geographical reach.

Text alternative for Figure 16 - Breakdown of Bursary Recipients by Region

Figure 16 is a pie chart that represents program data of HHR bursary recipients from fiscal years 2017-18 through 2019-20 and their regional distribution. Throughout this timeframe, there were bursary recipients in Alberta (14%), British Columbia (16%), the Atlantic Region (17%), Saskatchewan (13%), Manitoba (17%), the Northern Region (2%), Ontario (19%), and Quebec (2%). 1 bursary recipient was outside of Canada.

Source: Indspire Program Data, retrieved 2022.

For example, as shown Figure 16, bursaries over the three-year period between 2017 and 2020 have been awarded to recipients predominantly in the Ontario, Manitoba, Atlantic, and BC regions, followed closely by Alberta and Saskatchewan.^{Footnote 93}

Additionally, the data indicated that the most common programs of study with the health field for program recipients were Nursing, Medicine, and Kinesiology.^{Footnote 94}

Text alternative for Figure 17 - Breakdown of Bursary Recipients by Programs of Study

Figure 17 is a bar chart that represents program data of HHR bursary recipients from fiscal years 2017-18 through 2019-20 by their field of study. Throughout this timeframe, there were bursary recipients in the fields of Nursing (41%); Medicine (15%); Kinesiology/Human Kinetics (10%); Pharmacy (3%); Dental medicine/assistant/hygienist (3%); Occupational & Physical Therapy (3%); Public Health (2%); and all other fields (22%).

Source: Indspire Program Data, retrieved 2022.

Indspire conducts periodic surveys to assess the impact of the program in support of achieving intended outcomes of supporting Indigenous education and subsequent employment in healthcare-related fields. In 2017, bursary recipients reported a 42% employment rate, though 53% of graduates went on to pursue a subsequent post-secondary qualification.^{Footnote 95}

According to these same reports, in 2015, 80% of graduates of health-related programs were employed in roles servicing Indigenous populations. In 2017, this data was not broken down by field of study; however, of all bursary recipients, 61% of graduates were servicing Indigenous populations.

As funding has not increased over the years, the number of bursary recipients has decreased since Fiscal Year 2015-2016, after decreasing post-2018.

Overall, bursaries met 20% of financial need, with a variance between amounts requested and amounts rewarded of over $10M across the last five fiscal years.^{Footnote 96}

Partners described a lack of notable increase in First Nations working in the health care system, highlighting that people in First Nations communities lack the required capacity to devote time to training and professional development.

In interviews with ISC Program Representatives, it was noted that the HHR program only tackled a portion of the challenges at hand by providing an education to First Nations, Inuit, and Métis students and hoping they return to their communities to support the health needs. However, the gap, according to interviewees, is in the lack of funding available to allocate towards addressing the current challenges (e.g., ability to provide accommodations, compensation) in staffing nurses, physicians, and other health care workers in community.

Further, interviewees highlighted that the existing program supports Indigenous students by providing funding to pursue studies or professions; however, there is no evaluation of the effectiveness of the chosen programs. This indicates a potential opportunity for improvement, given the health needs identified around the necessary level of training, both medical and cultural.

According to interviews, the limited funding available through the program translates to an inability to meet demand despite a desire from Indigenous students to pursue health care education.

Stream 2: Community-Based Worker Training

The second stream under HHR provides funding to recipients in order to pursue community-based healthcare related training, in support of the program's immediate, intermediate and ultimate outcomes.

A review of HHR program data across the evaluation period indicates progress towards outcomes under Stream 2, with training provided to almost 4,700 community workers since Fiscal Year 2015-16.

The HHR program reached the target of providing training in 100% of regions in Canada by 2018.

One of the primary indicators tracked under the HHR program is the percentage of Indigenous people working in the health sector in Canada. The outlined target since 2019-20 has been 2.9%, which has been surpassed at 3% consistently. As a result of this continued success, the target for 2022-23 was raised to 3.3%. While the maintained target of 3% and the promising rise in Indigenous peoples working in health care since 2015 are positive results, the existing performance measure framework does not include the necessary level of analysis to conclude that the HHR program plays a significant role in increasing these numbers.

Text alternative for Figure 18 - Annual Percentage Change in Number of Indigenous peoples and Non-Indigenous People Working in Health Care in Canada

Figure 18 is a line chart with markers and represents Census Data from 2015-2021 noting the annual percentage change in the number of Indigenous peoples and non-Indigenous peoples working in health care in Canada. The year-over-year change in the percentage of the Indigenous population that works in health care was (from the baseline of 0%), up 15% 2015-16, up 4% 2016-17, up 26% from 2017-18, down 3% 2018-19, up 2% 2019-20, and up 16% 2020-21. The year-over-year change in the percentage of the non-Indigenous population that works in health care was (from the baseline of 0%), up 5% 2015-16, up 4% 2016-17, down 1% from 2017-18, up 2% 2018-19, unchanged from 2019-20, and up 6% 2020-21.

Source: Statistics Canada, 2023.

A review of literature highlighted that the number of Indigenous peoples working in health occupations has increased significantly between 2015 and 2021, rising from 28,300 to 50,200 (77%). As demonstrated in Figure 18^{Footnote 98}, the number has fluctuated dramatically year-over-year, while the number of non-Indigenous population in the health sector is comparatively more steady.

Despite this increase, Indigenous people only account for 3% of the healthcare workforce in Canada while making up 5% of the Canadian total population (as of 2021).^{Footnote 99} Interviewees also noted challenges in availability and sustainability of funding and the capacity of people in First Nations and Inuit communities to take on training and professional development activities. Further, it was noted that the parameters of the type of training program participants can receive (i.e., training for non-regulated workers and community-based workers in health promotion and disease prevention) can be restrictive and limit the opportunities for individuals to gain relevant expertise to address key health needs in First Nations and Inuit communities.

It was noted during interviews that the annual cycle of funding disbursement is misaligned with the multi-year lens with which plans are often developed, creating challenges in the ability of First Nations and Inuit to sustainably increase the number of community-based workers. It was suggested by one stakeholder that the restriction of funding exclusively to community-based workers has both positive and negative impacts towards the achievement of objectives, as smaller communities might be able to train external staff and bring them into community more effectively than training the limited number of members who may not be interested in pursuing health care training.

One internal stakeholder noted that the Department is often forced to hire third-party agency nurses to fill the existing human resource shortages in First Nations and Inuit communities; however, they are rarely culturally trained. Further, it was noted by one Program Lead that it would be beneficial for the federal government to invest in early education opportunities to increase awareness and interest in health care career paths.

ISC Regional Staff highlighted an opportunity to increase the level of promotion and awareness of programs to increase uptake of the program by clarifying the types of education and training that are eligible. It was suggested that the program explore the implementation of a national guide that outlines these parameters.

Impact of COVID-19 on Program Delivery

The impact of the COVID-19 pandemic on the core health needs of First Nations and Inuit was explored in the Relevance section of this report. In this section, the evaluation assesses the impact of the pandemic on the ability of the Cluster programs to effectively deliver their services.

In interviews, partners noted that the pandemic created several obstacles to program delivery, including:

• Limited access to communities to deliver care and engage First Nations and Inuit
• Diversion of resources towards COVID response and away from other health needs and priorities
• Staff in communities and within the Department experienced burnout, having the added burden of the COVID-19 response to their already excessive workloads
• Delays in Cluster program-funded project delivery

Despite the crisis, interviews highlighted that the pandemic resulted in some positive outcomes as well, including:

• Spotlight on First Nations health infrastructure gaps and needs
• Emphasis on value of eHealth technologies (e.g., access to virtual care)
• Emphasis on value of Accreditation (e.g., established governance structures and policies and procedures)
• First Nations adapted to the urgency of the pandemic, resulting in improved efficiencies in service delivery and quicker administration processes
• Collaboration with additional partners (e.g., HHR with Red Cross)
• Presence of the FNHA in BC facilitated a rapid response to COVID-19 in the Province and coordinated roll out of supports to BC First Nations

Access to Communities

It was noted by various interviewees that a key challenge for the delivery of health services throughout the pandemic was accessing First Nations and Inuit communities. To combat the spread of the virus, communities were required to completely shut down for months, creating increased barriers to delivering care. Further, maintaining communication with people in First Nations and Inuit communities was said to be particularly challenging, resulting in limited partner collaboration.

Diversion of Resources

When the pandemic hit in March 2020, it became the number one health priority worldwide, and First Nations and Inuit were no exception. According to interviews, the pandemic response required an all-hands-on-deck approach, dealing with quarantines, community shutdowns, vaccinations, and treatment for the virus. This left little time and even fewer resources to allocate to other health challenges. However, these other health needs did not cease to exist when the pandemic hit. In fact, many existing conditions were severely exacerbated by the virus or through the impact of the pandemic response. However, interviewees noted that there was no capacity in health treatment centers and no staff available to address anything but the most imminent of health threats.

The health care worker shortage was a challenge in First Nations and Inuit communities long before the pandemic; however, this shortage was dramatically exacerbated by the diversion of resources to pandemic efforts. Further, the labour demand on health care professionals was significant during the pandemic. Both frontline and administrative health care workers were overwhelmed with the non-stop crisis level urgency and were spread thin. As such, staff were unable to pursue additional training activities either.

Additionally, as a result of resources being diverted towards pandemic relief efforts, specific program activities were put on hold, such as the development of community health plans. HPQM program partners noted that this resulted in significant delays in the expected update or development of plans.

It should be noted that additional funding was provided by the Department to people in First Nations and Inuit communities to support the COVID-19 response. Without this additional injection of funding, existing health programs and services would have been even more adversely impacted. The impacts of the additional COVID-19 funding are further described below in the following sections.

Efficiency of Program Delivery

Throughout interviews, internal and external partners shared how First Nations were able to adapt in the face of the pandemic crisis and come together to deliver the necessary care to their communities.

Despite resource shortages from every perspective (financial, human, and material), interviewees noted how First Nations were able to achieve remarkable feats and apply their adaptive approaches to operate more efficiently. This highlighted the capacity that already exists in First Nations communities, and both internal and external program partners continuously expressed that with greater access to funding and resources, First Nations and Inuit could achieve so much more.

Interviews emphasized that through the pandemic, the Department was also able to work efficiently in order to provide short-term support rapidly. An example provided by a number of interviewees (14%) included the Department's procurement of short-term trailers and other physical pieces of infrastructures or measures (e.g., adapting schools, renting hotels) to be leveraged as isolation trailers for those infected with the virus, triage units to treat COVID patients, and overflow housing for health care staff.

Furthermore, ISC Regional Staff highlighted that alleviated reporting expectations during the initial years of the pandemic facilitated greater agility in program delivery because they were able to focus their efforts on emergency response and immediate needs instead of administrative tasks.

Lessons Learned for Future Health Crises

This evaluation also sought to understand if program partners learned any lessons to ensure better preparedness in the face of future health crises.

Emergency Preparedness

A significant number (20%) of interviewees noted that one of the key lessons learned throughout the pandemic was the importance of having emergency preparedness plans in place. In particular, partners noted the need for crisis management processes and mechanisms to be implemented in order to respond to any potential unprecedented disasters (e.g., floods, fires, etc.). Additionally, partners noted consideration should be made to medication distribution, vaccination programs, and health service delivery within a non-health centre context (i.e., triage units). Locating additional structures within which to provide care, vaccinations, and space for isolation was a challenge echoed by many. One Program Lead suggested integrating elements such as 'safe spaces' with separate entrances that can be used for immunization in the future.

A select number of partners highlighted the importance of community engagement on elements such as vaccinations to combat vaccine hesitancy. First Nation and Inuit communities were given priority access to COVID-19 vaccinations, which interviewees noted was very well appreciated; however, the process could have been even more effective had people in First Nations and Inuit communities had easy access to educational resources about the value and process of vaccinations in a pandemic setting.

As aforementioned, the Accreditation program's inclusion of emergency and disaster preparedness planning was particularly noted as valuable. In fact, when surveyed by the program, results indicated that health centres in communities that were accredited were better equipped to operate successfully during the pandemic, with 89% of organizations responding as such.^{Footnote 107} A review of the documented survey results demonstrated that First Nations and Inuit felt accreditation supported operations by ensuring policies and procedures were in place and protocols were followed, providing assurance to clients who felt safer knowing the facilities were accredited, having access to reliable information and webinars, and overall giving people in First Nations and Inuit communities a sense of confidence in their ability to provide quality care throughout the crisis.^{Footnote 108}

The evaluation recognizes that one of the primary challenges with implementing any of these lessons remains securing adequate funding. Interviewees continuously noted the difficulty of planning for the future when constantly working to address the present emergencies while chronically understaffed and underfunded.

Perceptions of COVID-19 Funding

In response to the COVID-19 pandemic, ISC committed to providing^{Footnote 109}:

• An additional $285.1 million to support First Nations-led public health response.
• Additional health care resources, including medical supplies and equipment.
• 160 additional temporary assessment, screening, and isolation units.
• Surge capacity supports to community-based services in First Nations and Inuit communities.

Many of the Cluster programs were allocated additional funding to address the COVID-19 relief response. The COVID-related expenditures per program are outlined below. As such, through interviews, this evaluation assessed the extent to which the additional funding supported the efforts in communities.

Interviews with both internal and external partners highlighted the following perceptions of COVID-specific funding:

• Funding was allocated and received with greater efficiency
• Funding was highly valuable to addressing COVID needs

Depending on the program, the region, and the community, perceptions regarding the utility of COVID-19 funding was varied. However, a large portion of internal partners perceived it favourably.

A review of program data from eHealth supports this favourable perspective, which indicated that the program was able to allocate both the first and second waves of off-cycle surge funding of $17.4M towards a number of valuable initiatives across Canada, including launching an Indigenous Virtual Care Clinic in Alberta, expand telehealth to four additional sites in Ontario, covering EMR implementation licencing fees, and more.^{Footnote 111} Additionally, the nearly $200 million provided through the HFP was used to provide surge infrastructure and other applied solutions in communities to ensure a swift COVID-19 response.

One Program Lead discussed the ways in which they were able to mitigate funding challenges, including planning costs line by line to ensure funding was fully optimized. Certain program representatives noted that the additional funding facilitated the management of the pandemic as well as mitigation of health and wellness impacts such as the pandemic trauma. Furthermore, partners shared that they were able to pivot with agility to be responsive to immediate crisis events, describing funding as flexible, urgent, and well received by First Nations. However, they also noted that existing program funding was often repurposed towards pandemic relief initiatives out of necessity, and as such, additional COVID funding often could not bridge the existing and further exacerbated gap in resources.

Relationships Between ISC HQ and ISC Regions

Perceptions of partners about the relationship between ISC HQ and Regions varied across interviews. Of the regional partners who were specifically asked about the effectiveness of their relationships with ISC HQ, a large portion of respondents rated it as Effective (45%) or Neutral (27%), while the rest evenly rated (9%) across the other three options.

Text alternative for Figure 23 - Effectiveness of Relationships Between ISC HQ and ISC Regions

Figure 23 is a bar chart that illustrates key informant interviewees perception of the effectiveness of relationships between ISC headquarters and ISC regional staff members. Responses were on a scale and include Very Ineffective, Ineffective, Neutral, Effective, and Very Effective. The responses of program leads were Very Ineffective (9%), Ineffective (9%), Neutral (27%), Effective (45%), and Very Effective (9%).

Source: Interviews by ISC Evaluation, 2022-2023.

When asked to elaborate, internal partners noted that relationships were good but had areas for improvement, particularly in the areas of organizational culture and communication. It was noted that the nature of ISC's mandate to transfer services and the large-scale transformation this would entail creates natural challenges with some ISC staff who may be more resistant to change. The required organizational culture for change was noted to be lacking by a significant number of interviewees.

In regard to communication, partners noted that internal communication continues to present challenges because the role of ISC HQ in program delivery has changed over the years. According to interviews, there is a lack of required support from ISC HQ to regions in terms of clear directives and sustainable resources. Some Cluster programs, such as the HFP, have made recent efforts to improve the relationship between ISC HQ and the regions by hosting bi-lateral meetings twice a month and gaining an increased understanding of the challenges and lessons learned their respective groups experience. It was also noted during interviews that consistent messaging from ISC HQ to the regions to ensure that the regions and subsequently the people in First Nations and Inuit communities they are supporting have a clearer understanding of the funding that is available in order to be able to better support First Nations and Inuit in affirming their vision of control.

Relationships Between Regions and First Nations and Inuit

Overall, perceptions of relationships between ISC regions and First Nations and Inuit were positive. Of the regional representatives who were asked to comment specifically on their relationships with First Nations and Inuit, the majority rated the relationships as Effective (58%) or Very Effective (33%).

Text alternative for Figure 24 - Effectiveness of Relationships Between ISC Regions and First Nations and Inuit

Figure 24 is a bar chart that illustrates key informant interviewees perception of the effectiveness of relationships between ISC regional staff and First Nations and Inuit. Responses were on a scale and include Very Ineffective, Ineffective, Neutral, Effective, and Very Effective. The responses of program leads were Very Ineffective (0%), Ineffective (0%), Neutral (8%), Effective (58%), and Very Effective (33%).

Source: Interviews by ISC Evaluation, 2022-2023.

Regional representatives highlighted the importance of transparency, honesty, and collaborative communication in their ability to build lasting relationships with people in First Nations and Inuit communities. The need to manage expectations and delineate between what First Nations and Inuit want to do and what they need to do was noted to be specifically challenging. Interviewees emphasized that building meaningful relationships allows First Nations and Inuit to feel comfortable approaching the regions with their priorities. However, it was noted during interviews that limited capacity and staffing shortages both within ISC Regions and within communities creates obstacles for both groups being able to dedicate time for meaningful engagement and collaboration.

It was noted in a select number of interviews that relationships were strained during the pandemic due to the loss of regular, face-to-face contact and engagement; however, the expectation is that this will change as communities begin to open their doors once more and travel resumes.

Partners highlighted that any changes in program regional leads should require orientation, training, and relationship building in order to maintain the relationships built between ISC regions and First Nations and Inuit; however, adequate resources to ensure this occurs is currently not provided.

Relationships Between First Nations and Inuit and Implementing Partners

During interviews, it was noted that relationships between First Nations and Inuit and implementing partners are strong and effective. Interviewees shared that there is a desire to increase the level of integration between community facilities and potential delivery partners, such as regional health authorities or organizations such as Aboriginal Health Access Centres.^{Footnote 114}

HHR and QIAP partners noted effective relationships between First Nations and Inuit and accrediting bodies as well as strong relationships with partner groups, including the ITK and AFN. Partners interviewed from accrediting bodies highlighted extremely effective relationships with people in First Nations and Inuit communities, which allow them to better understand and respond to their needs.

Relationships Between Implementing Partners and ISC

It was noted by one Implementing Partner that as a result of their relationship with ISC strengthening through the pandemic, they were able to operate more effectively and efficiently (i.e., seek approvals with more ease).

Implementing partners also noted the value of cultural competency training being provided to ISC staff to ensure the appropriate level of understanding to operate effectively. It was highlighted that there have been occasions where Implementing Partners feel they must take it upon themselves to 're-teach' this training to staff in the absence of the required training and cultural competency.

Relationships Between Various Implementing Partners

A select number of implementing partners noted the gap in collaboration with other implementing partners in the same space, highlighting the potential value of working together to support First Nations and Inuit rather than as competitors. Additionally, it was highlighted by implementing partners that these programs are in a complex set of relationships with various related departments (e.g., Crown-Indigenous Relations and Northern Affairs Canada, Health Canada, Public Health Agency of Canada, etc.) and the communication amongst these parties should be improved to clarify roles and responsibilities (i.e., support a whole-of-government approach).

To further supplement the information gathered through interviews, respondents to the survey conducted were asked to indicate which relationships needed to be strengthened in order to improve the Cluster programs' functions. In alignment with the above noted interview data, survey results suggest opportunities to improve relationships between all program partners, though the relationship between ISC HQ and ISC Regions was highlighted the most frequently, followed by the relationship between ISC Regions and First Nations and Inuit, and closely afterward by the relationship between ISC Regions and Provinces/Territories (PT).

Text alternative for Figure 25 - Which relationships need to be strengthened to improve the program's function?

Figure 25 is a bar chart that illustrates survey respondents' responses to the question "Which relationships need to be strengthened to improve the program's function?" Internal (to ISC) respondents noted the following relationships needed to be strengthened: ISC headquarters and ISC regional staff (34%); ISC headquarters and Provinces/Territories (11%); ISC regional staff and Implementing Partners (16%); ISC regional staff and First Nations and Inuit (21%); ISC regional staff and Provinces/Territories (18%). External (to ISC) respondents noted the following relationships needed to be strengthened: ISC headquarters and ISC regional staff (26%); ISC headquarters and Provinces/Territories (10%); ISC regional staff and Implementing Partners (18%); ISC regional staff and First Nations and Inuit (22%); ISC regional staff and Provinces/Territories (24%).

Source: Survey deployed by ISC Evaluation, 2022.

Throughout interviews, several partners shared feelings of frustration related to the inability to surpass the surface relationships and make substantial progress towards real change. Further, interviews highlighted that ISC has been experiencing consistent turnover, and a review of internal ISC data1 indicated that in recent years, the churn rate of HQ and regional program staff working in the Cluster programs rose from 4% in Fiscal Year 2020-21 to 12.8% in Fiscal Year 2021-22. In Fiscal Year 2020-21, turnover was particularly high within the eHealth Infostructure program (6.2%) and overall, within the Alberta (13.1%) and Manitoba (8.7%) regions.

This was noted to be particularly challenging following FNIHB's transition from Health Canada to ISC, given the significant turnover and adjustment period required for new staff. This was further exacerbated by the pandemic, which created even more turnover, along with challenges in capacity and the ability to engage and collaborate with other partners, potentially due to challenges associated with having to limit in-person interactions.

Clarity and Division of Roles and Responsibilities

Survey data indicated that partners have a varied perception of the clarity and adequacy of roles and responsibilities within their respective programs. Internal partners agree (47%) most consistently, while external partners are neutral (36%).

Text alternative for Figure 28 - The role and responsibilities of this program and its staff are clearly defined, well understood and communicated effectively

Figure 28 is a pie chart that illustrates survey responses to the statement "The role and responsibilities of this program and its staff are clearly defined, well understood and communicated effectively". Responses were on a scale and include Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, I don't know, and Not Applicable. Internal (to ISC) responses were Strongly Agree (3%), Agree (47%), Neutral (19%), Disagree (19%), Strongly Disagree (36%), I don't know (14%), and Not Applicable (0%). External (to ISC) responses were Strongly Agree (21%), Agree (14%), Neutral (36%), Disagree (14%), Strongly Disagree (14%), I don't know (0%), and Not Applicable (0%).

Source: Survey deployed by ISC Evaluation, 2022.

While internal partners generally responded positively in the survey about the clarity of roles and responsibility, interviewees noted a need to improve the clarity of the division of roles and responsibilities between HQ and ISC Regions, particularly when faced with challenges associated with insufficient funding. According to interviews, ISC HQ used to be responsible for managing program budgets and allocating funding to regions based on workplans that are submitted by the regions. However, the roles have since changed and ISC HQ now has minimal control over funding allocations; it is the regions that hold the authority and determine how funding is allocated within the region. Due to internal changes such as this, it was noted in one focus group that there is sometimes confusion internally around who to contact for when questions arise about program administrative processes and approvals. Further, partners highlighted that leadership changes that occur both internally within ISC and externally within First Nations and Inuit communities can cause shifts in priorities or approaches to address those priorities. This can result in challenges in maintaining clarity of roles and responsibilities both internally between HQ and Regions, and subsequently between regions and First Nations and Inuit. In particular, internal partners noted a need for clarity around roles and responsibilities within service transfer, including post-transfer support to First Nations and Inuit. There may be an opportunity to ensure internal, foundational ISC processes that support the achievement of the department's goals related to the Cluster's programs are clearly defined, documented, and communicated. These processes should allow for a certain degree of flexibility should priorities shift but should also support an increased alignment of expectations between program partners and First Nations and Inuit around program-related roles and responsibilities.

Communication About Service Transfer

In the survey conducted, internal partners were asked whether they perceive information regarding service transfer was communicated effectively to their teams. Results were varied, with a large portion of respondents indicating that they Agree (31%), were Neutral (25%), or Disagree (22%).

Text alternative for Figure 29 - Information about service transfer is communicated effectively to me and my team

Figure 29 is a bar chart that illustrates survey responses to the statement "Information about service transfer is communicated effectively to me and my team". Responses were on a scale and include Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, I don't know, and Not Applicable. Internal (to ISC) responses were Strongly Agree (3%), Agree (47%), Neutral (19%), Disagree (19%), Strongly Disagree (36%), I don't know (14%), and Not Applicable (0%). Note that this question was not included in the survey that was provided to external respondents.

Source: Survey deployed by ISC Evaluation, 2022.

In interviews, the lack of clarity in communication about the departmental mandate of service transfer was said to be due to the following factors:

• Departmental transfer of programs from Health Canada to ISC and resulting turnover resulted in a lack of understanding of the departmental mandate, particularly with regards to how the Cluster programs are meant to be supporting the achievement of broader service transfer to First Nations and Inuit. It was also noted that there is a lack of clarity around "small 't' transfer" of specific health programs and services versus full-scale "big 'T' transfer" of complete health systems means for both ISC and people in First Nations communities, particularly about how the former may present barriers to the latter, or how the former may be used to support the achievement of the latter.
• Cluster program siloes result in a lack of alignment in approach to service transfer creating difficulties in operationalization.
• Information sharing protocols act as a barrier, as documents that are classified cannot be shared from ISC internal partners and external implementing partners (i.e., FNHA) in alignment with the Security of Information Act, which restricts who can be communicated with, precluding conversations and relationship-building efforts with key partners.

Partners noted that increased collaboration across Cluster programs around service transfer messaging would improve alignment in approach, particularly because the Cluster programs' objectives are already well-aligned with each other (i.e., from a program design perspective). Additional details about collaboration amongst Cluster programs are provided in the next Finding.

Necessary Conditions for Service Transfer

Throughout this evaluation, partners were asked to share their perspectives on which conditions are required to be in place in a community to achieve a state of readiness for service transfer. Most interviewees agreed that in order to successfully transfer services, First Nations and Inuit require sustainable funding, access to support and training, effective relationships with program partners, most specifically ISC staff, and governance structures. It was also emphasized that the approach to transferring services is key to its potential success.

Effective Relationships and Stakeholder Buy-In

First and foremost, to be able to transfer services effectively, people in First Nations and Inuit communities need to have the capacity to manage the services in the long-term. As such, the transition between current state and a state of transfer requires effective relationships between program partners and First Nations and Inuit to support the building of the necessary capacity.

Interviewees noted a need for openness, cultural awareness and safety, and open-dialogue communication in relationships in order to ensure partners are understanding of the wholistic picture of what elements must be integrated for services to be appropriate for First Nations and Inuit. For a successful relationship, program partners must engage with First Nations and Inuit in a consistent and meaningful way to build trust, gain a better understanding of their identified needs, and support First Nations and Inuit assumption of true control in the allocation of resources. This trust must also be present in fiscal relationships and manifested through less reporting and planning requirements. Interviews emphasized that people in First Nations need the freedom to allocate the provided resources where they see fit.

Further, it was highlighted that transfer cannot occur solely on the basis of the desire of people in First Nations and Inuit communities, but rather that buy-in from all partners, including the federal government, Provinces/Territories, and other relevant health entities, is required to ensure First Nations and Inuit can access the appropriate resources for capacity building and an effective transition.

It was noted by regional representatives that consideration should be made to the maintenance of key residual roles within ISC Regions to continue to provide support during the transfer of control of services. Engagement with First Nations and Inuit would be required in order to understand and confirm that there is a need for lighter, but continued, support from ISC Regions during the process of service transfer.

Knowledge and Expertise

Another condition necessary for successful service transfer, related to effective relationships, is the knowledge and expertise required within key roles (e.g., health directors, health administrators, management roles, etc.) in First Nations and Inuit communities for the provision of the services being transferred. Interviews highlighted the value of program partners outside of First Nations and Inuit communities who can share their knowledge and expertise and provide the necessary training for areas where capacity may not be as developed.

Similar sentiments were expressed regarding access to resources and information. In order to effectively transfer services, people in First Nations and Inuit communities need to understand what is involved and how best to prepare for service transfer. The expectation, according to interviews, is that ISC should support First Nations and Inuit in obtaining that information. This could include facilitating knowledge sharing, where best practices and lessons learned from ISC and relevant program partners are shared in a consistent and widespread manner to First Nations and Inuit.

Sustainable Funding

Funding is required to build capacity in First Nations and Inuit and ensure patient safety, both from a physical infrastructure perspective (e.g., maintenance of health facilities, appropriate equipment) and a staff perspective (e.g., training and expertise). Only when First Nations and Inuit can confidently plan programs and projects knowing that funding will continue to support these initiatives, with consideration of core health needs, can First Nations and Inuit be in the best state to transfer services.

The importance of investing into infrastructure (i.e., physical, technological, governance etc.) in order to achieve service transfer was noted several times across stakeholder groups, with one internal stakeholder specifying that a large proportion of their success thus far is due to expenditures in the infrastructure space. Infrastructure is a foundational piece to the ability of First Nations and Inuit to provide adequate and safe care and is considered a necessary condition for service transfer.

Governance Structures

Another necessary condition that was noted frequently amongst various stakeholder groups was that of an appropriate governance structure in place.

Service transfer is more than a simple transfer of funding control to First Nations and Inuit; rather, it needs to be a transfer of ownership of programs and services. Interviewees noted the need for appropriate governance structures with two-way accountability (i.e., accountability of ISC and accountability of First Nations and Inuit) in order to ensure resources are allocated efficiently and effectively to achieve objectives of First Nations and Inuit programs and services. According to interviews, it is imperative that accountability and reporting frameworks be defined and developed in partnership with First Nations and Inuit. The value of strong governance lies in the ability to provide oversight over programs and services through clearly defined processes and procedures, roles and responsibilities, and intended outcomes, as well as defined indicators to measure performance against those outcomes. Having these systems in place allows for improved knowledge sharing, increased standard of quality, and a greater understanding of strengths and weaknesses to drive strategic planning.

In discussions with representatives from the FNHA, it was specifically noted that the governance structures in place, including formal reporting mechanisms (financial and narrative reporting), participation in partnership tables, and informal communication channels between key partners are instrumental in their continued success. Other governance-related conditions that can also facilitate successful service transfer include defined policies and procedures, data governance strategies, and change management plans.

This condition links back to the value stated by program partners of pursuing accreditation, given that when accredited, institutions are considered capable of running health systems in alignment to a set of clearly defined, approved, and accepted standards. With many of these governance pieces already in place through accreditation, QIAP partners noted that service transfer occurs more smoothly as a result.

Approach to Transfer

Above, it was noted that while the intent behind service transfer is aligned to the needs of First Nations, there were concerns around the approach to transferring services. Specially, interviewees noted the need to engage with First Nations to understand which services they are willing and currently capable of assuming full control over in order to better focus on building capacity in those areas.

It was also highlighted by a select number of internal partners that the objective does not always have to be an immediate and full transfer of service. There is value to the small victories (i.e., small-scale transfer) that can contribute to a greater transformation of health services. However, this was somewhat contradicted in other interviews, where it was noted that the disjointed nature of small-scale transfer can create siloes and potential strategic misalignment when broader Health Transformation is the eventual goal.

Despite the inconsistent perspectives from interviews, what was clear was the importance of considering the approach to transfer in order to properly understand its potential success or pitfalls. If small-scale, project-based transfer is the best way forward for some First Nations and Inuit, there should be appropriate consideration made to how this can be accomplished and what the implications will be for other related projects, entities, and partners. More broadly, to contribute to successful service transfer, regardless of the scale, efforts should be put towards ensuring the necessary conditions for service transfer outlined in this section are in place.

Potential Barriers to Service Transfer

Insufficient Funding

According to the majority of interviewees (45%), the most prevalent barrier to service transfer is the absence of sustainable funding. First Nations and Inuit are sometimes deterred from taking control of services due to the lack of access to sufficient funding that can maintain the services in the long-term.

Throughout interviews, it was emphasized that the lack of funding towards the Cluster programs, and subsequently the people in First Nations and Inuit communities they serve, is insufficient to achieve the objective of the individual programs and by extension, the broader Departmental goal of service transfer.^{Footnote 118}

Due to insufficient levels of funding, First Nations and Inuit are unable to adequately address all areas of greatest need. When considering the social determinants of health, infrastructure needs, and emergency health services, it is often difficult to decide which area is of greater priority, particularly when faced with limited financial resources to support all areas of need. On the one hand, emergency services are required to address current crises; however, on the other hand, addressing root challenges, such as social determinants of health, is necessary to reduce and/or prevent the number of health emergencies occurring.

A select number of interviewees (6%) also noted the absence of comprehensive health care, as some health care staff may be funded through various avenues (e.g., doctors could be funded by both the federal government and provincial government, nurses could be federal employees, and other health care staff may be directly from community). The challenge of having multiple jurisdictions providing health care services on reserve can result in a lack of integrated care, particularly when roles and responsibilities are not clearly defined and overarching policies and procedures (e.g., sharing patient data and information between various parts of a health care system or between different types of health care working) are not in place to guide overall health care service delivery in communities. Therefore, sufficient funding is required not only to meet the broad range of needs of First Nations and Inuit, but to also support greater integration of health care services, an aspect that is HSIF's primary objective.

ISC Staff Turnover

As noted above in Finding #16, according to interviews, the level of turnover in staff at ISC has created barriers to the ability of people in First Nations communities to build relationships and access support in key areas. For example, one First Nations Representative mentioned that they were receiving support for data analysis and access from ISC regional staff; however, when the ISC representative changed positions, the First Nation was no longer able to receive that support. The constant need to rebuild relationships erodes at the trust that First Nations and Inuit have in the ability to make progress and remain aligned with ISC in a common path towards eventual service transfer.

Various Stages of Readiness

With regards to small "t" transfer, one area that was highlighted often throughout interviews was the challenge that stems from the different sizes of communities as well as the various stages of readiness they can be in for service transfer. With regards to big "T" transfer, fully transferring health programs and services to an entire region or province may be difficult to accomplish when all communities in that region are not yet equipped to take on services, or if there is limited capacity of a representative First Nations or Inuit-led governance body who will deliver the services.

It was noted by select program representatives that it is important to recognize that people in First Nations and Inuit communities may require varying levels of support in delivering services, given that some communities are already operating independently while others may be able to take on some services but not all. Overall, there is a need to support capacity building within communities to improve broader readiness for transfer. However, the challenge still remains that service transfer is not a one-size-fits-all approach, and flexibility is required to meet the unique needs of First Nations and Inuit when approaching service transfer. It should also be emphasized that the programs and services that are to be eventually transferred to First Nations and Inuit must themselves be in an appropriate state of readiness for transfer (e.g., they are sufficiently funded, governance mechanisms are established, mechanisms for knowledge sharing and transfer are established, etc.). It is important for ISC to work towards achieving a level of readiness in their health programs and services to ensure First Nations and Inuit are not faced with the additional burden of 'rehabilitating' programs and services before they are able to fully assume control over them.

HFP

In discussions with program representatives of the HFP, interviewees noted varying funding sources that have been allocated to support the program in more recent years, including from the 2021 Canada Human Rights Tribunal (CHRT) 41 Order, which outlines orders for Canada to provide funding towards the purchase and construction of capital assets for the delivery of First Nations child and family services and services associated with Jordan's Principle.^{Footnote 120Footnote 121} Further, it was noted that funding is received under the Indigenous Early Learning and Child Care (IELCC) Framework that is allocated towards minor capital projects. However, HFP partners highlighted the lack of sufficient consideration of changes in costs of construction and noted that the current economic state has not accurately been reflected in the program's annual funding allocations.

A significant (45%) number of interviewees emphasized the impact of unsustainable funding, with particular focus on the inability to invest in operations and maintenance activities. According to interviews, the majority of funding received under HFP is allocated towards capital projects, including minor repairs and major construction projects, with little available to allocate towards sustaining facilities over the long-term.

HSIF

Similar to the HFP, both internal and external partners noted a challenge with the sustainability of HSIF funding. For example, applicants submit proposals to access funding through HSIF. However, the funding is time-limited, meaning that people in First Nations and Inuit communities are required to use resources to regularly develop proposals to access additional funding for the purpose of continuing to make progress in achieving their intended objectives and meeting their respective community's needs. This also affects the ability of First Nations and Inuit to effectively plan for the long term, as it is only with sustainable funding that community-led projects and initiatives can be maintained and provide benefits for First Nations and Inuit over a longer time horizon.

HPQM

In interviews, it was noted by a select number of partners that HPQM funding is sometimes used as an incentive for First Nations and Inuit who have taken on greater control of health services. This results in less funding and resources being allocated to First Nations and Inuit who lack the capacity to develop a health plan. This poses a unique challenge as the communities who do not have a health plan in place or who may not exercise great amounts of control over their health service delivery are often the ones who are in greatest need of funding support for health planning activities in order to build a stronger foundation on which to deliver health services that meet the unique needs of their respective communities.

QIAP

The funding amount for the Quality Improvement and Accreditation Program in Budget 2018 was $22.5M across 2018-2021, with an ongoing $4.5M.^{Footnote 122} QIAP partners outlined that no new funding was received since 2017/2018, when funding to the Accreditation program was cut by 75%. A significant number of partners (43%) and most Program Leads (71%) highlighted that funding does not adequately support the QIAP or HPQM programs. Despite noted success, Program Leads shared that they have halted marketing and awareness efforts as the lack of funding results in an inability to meet the rising demand for accreditation activities.

HHR

While there are many health needs associated with HHR, funding for the program is not permitted to be allocated towards broader training areas, including: continuing education for regulated health professionals, curriculum development or modification, wages/salaries of community-based workers, and staff replacement costs to attend training.^{Footnote 123} Interviews with First Nations representatives noted that supporting these areas would be beneficial for First Nations in meeting their health human resource needs. Despite this, and similar to the QIAP, there continues to be a high demand for this program. However, due to limited program funding allocations, the HHR program has only been able to meet approximately 50% of the demand.

eHealth

Partners involved with the eHealth program emphasized that the funding levels available to allocate to First Nations are insufficient in the face of long-term and continuous expenses related to eHealth technologies. Interviewees noted that First Nations are often required to provide their own funds to be able to maintain implemented systems (i.e., EMR), despite having very limited resources to do so. Program partners highlighted that while there have been success stories in which First Nations have been able to successfully secure additional funding or self-fund maintenance activities, First Nations should not be required to be responsible for these costs, particularly when there are often many other critical health needs that First Nations are seeking to address.

It was further noted that access to funding can fluctuate as a result of changes in leadership roles, including political parties. Partners shared examples of making progress under one leader that is then diverted when the position is transitioned, demonstrating a variance in priorities and perspectives.

In addition to the program-specific funding challenges noted above, the following areas were also noted more broadly by interviewees as challenges:

• Cultural safety and humility: As aforementioned, allocating funding towards increasing access to a health facility or health services is not enough. People in First Nations and Inuit communities need to have access to culturally safe care in order to be comfortable seeking and receiving services. In interviews, it was noted by a select number of partners that even when adequate levels of funding for program activities are allocated, they often do not consider the additional activities required to integrate cultural or traditional practices in broader service delivery. Other program partners noted inadequate levels of funding to ensure requirements are met for culturally safe and quality care, such as occupational health and safety requirements and patient navigators.
• Needs-based funding: Based on a review of the standard terms and conditions for ISC transfer payments under the Health Infrastructure Support Authority (i.e., the program authority under which the Cluster programs fall within), funding recipients are allocated funding based on the conduct of a readiness assessment, including a General Assessment that is conducted to develop a risk profile for recipients which outlines expectations around the level of monitoring required, the type of plan expected, and the appropriate funding model to select. Funding is provided through one of four funding models, including:
  • Set: Funding agreement with the least amount of flexibility where recipients deliver programs and services as set out by FNIHB. Recipients can only reallocate funds within the same budget activity with written approval by the Minister within the fiscal year reporting period.
  • Fixed: Allows for funding to be reallocated to other functional areas within the same budget activity. Unexpended funding can only be carried forward to the next fiscal year to complete activities that had already been initiated.
  • Flexible: The recipient establishes a multi-year work plan that includes a health management structure, priorities, objectives, activities, and a budgetary plan. Recipients are able to carry over program funding annually for the duration of the agreement, although any unspent funds at the end of the agreement must be returned.
  • Block: The recipient establishes a health plan that includes a health management structure, priorities, objectives, activities, reporting requirements, and health programs and services. Recipients are able to reallocate funds across authorities and can retain any surpluses to reinvest in health priorities.

  Funding is provided to support the development of these plans on the basis of estimates provided by the respective regions. It was noted by one stakeholder that in block agreements, population numbers are used to allocate funding amounts; however, when the agreement is being renewed, there is no opportunity to adjust the agreement amount to reflect a larger population or any new needs that have arisen. Further, they highlighted that population calculations often do not account for those who live off-reserve but still use services provided by First Nations.

  There is a perception amongst partners that the allocation of funding can be improved to increase effectiveness of dollars. Particularly, it was noted that funding should be allocated on a needs-basis, rather than based on a per-capita formula. Interviewees emphasized that needs are not uniform across First Nations, and as such, one community may require a higher proportion of funding towards one particular health area, while another may not need as much in that same area but need more in yet another. Provincial governments may indicate certain overarching needs, for which funding is then secured and distributed based on population sizes, leaving First Nations to plan on the basis of what is received. Throughout interviews, a significant number of program representatives (43%) noted that the existing funding allocation formulas are not appropriate for the accurate measurement of need, as they tend to focus on metrics, such as population size, that are not always indicative of relevant health needs. Interviewees noted that this is not beneficial to allowing First Nations to highlight the core needs for which they require funding, nor is population size always indicative of greatest level of need.

  Of note, the HFP introduced a needs-based prioritization framework during the evaluation period. Program representatives noted that previously, there was a challenge in the prioritization of funding, which historically resulted in allocation of funding towards communities who are ready but not the ones who exhibit the greatest needs, which is not necessarily accurate. To overcome this challenge, the program put in place a needs assessment framework with the purpose of implementing a more consistent process for evaluating, costing, and prioritizing major capital investments. The framework allows the program to better direct investments towards communities and projects of greatest need (e.g., projects that address life, health, and safety needs are designated as high priority).^{Footnote 124} There may be an opportunity for the other Cluster programs to share best practices, lessons learned, and knowledge with the HFP's approach to determine if there are aspects that can be adopted into their respective funding formulas to support needs-based funding allocations.

Overall, the cost-effectiveness and the Cluster's impact on outcomes could be improved if health infrastructure support programs were better supported. For example, accredited health centres have demonstrated efficiencies in overall program delivery, reducing costs and equipping health centres and First Nations with the right tools to address health needs in an efficient and effective manner. Additionally, and of note, the Evaluation of the BC Tripartite Framework Agreement on First Nations Health Governance (2019) emphasized that the FNHA's strategic position and partnerships with both the federal and provincial governments facilitated new investments from both levels of governments to support the transfer of FNIHB services to the FNHA. In particular, sufficiency of funding, both in magnitude and timeframe, are required to support a smoother process of service transfer.

The Cluster programs have continued to make progress towards the achievement of their respective intended outcomes despite limited increases to overall funding levels. However, the Cluster programs would be able to make more significant progress towards their objectives if there was sufficient funding to support doing so.

First Nations Health Authority in BC

Although the BC Tripartite Relations program was not formally evaluated as part of this Cluster evaluation, it was included with the intent to learn from its design and delivery model and glean best practices and lessons learned.

The transfer of health services and programming from FNIHB – BC Region to the FNHA is broadly seen as successful and noted through both interviews and literature review as a model for service transfer. The recently conducted Evaluation of the BC Tripartite Framework Agreement on First Nation Health Governance highlighted several factors that contributed to the success of the transfer, including:

• Strong partnerships between First Nations in BC, the FNHA, the federal government and the provincial government, including a high level of collaboration.
• Commitments from all parties towards cultural safety and humility, the 7 Directives^{Footnote 131}, and the Vision and principles of the Framework Agreement.
• Flexibility in the approach to achieving successful service transfer.
• Dedicated and sufficient funding for various aspects of service transfer, such as dedicated funding for community engagement activities or for information management/information technology systems development and maintenance.

Key lessons learned in the transfer of health services of programming to the FNHA were highlighted in both the previously conducted evaluation and in interviews with program partners. They included the following:

• Service transfer does not occur overnight. The process and transition can take a long period of time to ensure all aspects of a successful service transfer have been considered, implemented, and matured (e.g., IM/IT systems, governance and organizational structures, etc.).
• Integration of various jurisdictions and levels of government is necessary for successful service transfer. In particular, there must be authentic buy-in from all key partners as well as clearly defined responsibilities and accountabilities that are actively committed to.
• The long-term sustainability of funding and resources is required to ensure service transfer can continue to be successful for years to come. Long-term planning efforts are required at various levels of community and government to better support the sustainability of health programs and services.
• Robust health-related data is required to support First Nations in advocating for targeted funding based on their needs and priorities.

Overall, the transfer to the FNHA was considered successful due to a variety of reasons. The two primary ones highlighted in the previously conducted evaluation and the interviews were the following: Firstly, it has allowed First Nations in BC to create a First Nations governance structure. It is through the emphasis on the importance of First Nations governance that allows First Nations in BC to be self-determining in the area of health services. A clearly established First Nations governance structure has also allowed for increased access to both federal and provincial funding in the area of health services. Secondly, the high degree of commitment from all levels of government was considered a great success, as it allowed a smoother process of service transfer in BC while remaining flexible and adaptable to the needs of BC First Nations. The relationships between the FNHA, BC First Nations, and various levels of government have been improved and there is a degree of trust that has been established.

National Aboriginal and Torres Strait Islander Health Plan (NATSIHP)

Australia's federal government developed the National Aboriginal and Torres Strait Islander Health Plan (NATSIHP) in partnership with Aboriginal and Torres Strait Islander peoples with the goal of achieving better health outcomes through the prioritization of community-controlled health services.

The plan emphasizes the importance of addressing the social and environmental factors that affect Indigenous health, ensuring health care delivery is culturally safe for Indigenous peoples, and achieving equality of health status and life expectancy between Aboriginal and Torres Strait Island people and non-Indigenous Australians by 2031.^{Footnote 132} The NATSIHP and its intended outcomes were developed to complement the National Agreement on Closing the Gap (the National Agreement), which was developed to address the inequalities experienced by Aboriginal and Torres Strait Islander people.

An Implementation Plan was developed to define the Australian Government's role in executing the NATSIHP. It set out twenty goals, including goals such as increasing the proportion of Aboriginal and Torres Strait Islander women attending at least one antenatal visit in the first trimester in their pregnancy, increasing the rate of Aboriginal and Torres Strait Islander children who have at least one annual health check, and reducing the rate of Aboriginal and Torres Strait Islander youth who smoke. The Implementation Plan also defined indicators for each goal, as well as historical data, data sources, projections, and any potential limitations.^{Footnote 133} The Australian Government considers the achievement of these twenty goals as success of the NATSIHP; however, it is also important to note that there were a series of strategies defined in the Implementation Plan that underpin the NATSIHP and its overall objective. These strategies can be considered as best practices for when federal governments are seeking to partner with Indigenous peoples when addressing health inequities, and include, but are not limited to:

• Meaningful partnership and engagement with Aboriginal and Torres Strait Islander peoples, including their representative bodies, throughout all aspects of the NATSIHP and its Implementation Plan, including planning, service delivery, and evaluation.
• Dedicated investments to build the capacity and capability of Aboriginal Community Controlled Health Organizations (ACCHOs) to ensure identified needs of Aboriginal and Torres Strait Islander peoples are met.
• Addressing social and cultural determinants of health, including improving school attendance and workforce participation as well as building safe communities.
• Establishing clear partnerships and accountability mechanisms, including assessing progress and performance of the plan on a regular basis.^{Footnote 134}

New Zealand Māori Health Strategy – He Korowai Oranga

He Korowai Oranga focuses on a wholistic vision of Māori health. The strategy was first published in 2002 and is intended to provide an overarching framework for the federal government and the health and disability sector more broadly in New Zealand to achieve pae ora – or healthy futures for Māori. It was subsequently revised in 2014. Whakamaua: Māori Health Action Plan 2020-2025 was then published to provide a clear path forward for the federal government and the entire health and disability system to implement He Korowai Oranga.

Best practices and conditions for a successful realization of He Korowai Oranga include, but is not limited to:

• A commitment to Te Tiriti o Waitangi (Te Tiriti), the framework that describes the Crown's obligations in New Zealand's health and disability system as it pertains to Māori. This includes enabling Māori self-determination, providing adequate resources for Māori health and disability services, ensuring all health and disability services are provided in a culturally appropriate way, and ensuring Māori are co-designers with the Crown of the primary health system for Māori.
• Establishing meaningful Māori-Crown partnerships and relationships that are built on a foundation of trust and confidence.
• Enabling Māori leadership and participation in key governance mechanisms and decision-making processes, including building capacity for future Māori health and disability leaders.
• Cross-sector integration and a coordinated, whole-of-government approach to address social determinants of health and support the provision of culturally safe care.
• Establishing mechanisms to collect and use data in a meaningful way, including understanding differences in health outcomes and using the data to support decision-making innovation, and continuous improvement of the quality of care for Māori.
• Accountabilities of the federal government and other key partners are clearly defined, including transparent performance and reporting mechanisms.^{Footnote 135}

Southcentral Foundation's Nuka System of Care

The Nuka System of Care is a model of Indigenous-owned healthcare that describes a wholistic health care system that is created, managed, and owned by Alaska Native people to achieve wellness in all aspects – physical, mental, emotional, and spiritual. It was developed by the Southcentral Foundation, a non-profit health care organization based in Alaska, and is the model on which the FNHA was based.

As part of the Nuka System of Care, Alaska Native people are 'customer-owners' of the health care system. Customer-owners are at the center of this model and focus is placed on building meaningful relationships with customers-owners in order to achieve improved health outcomes. This includes establishing mutual trust between service providers and customer-owners as well as collaborating with partners from various jurisdictions and sectors.

To ensure customer-owners design, implement, and maintain control of their own health care programs and services, Southcentral Foundation established multiple communication and feedback mechanisms to ensure the perspectives of customer-owners from over 200 tribes in Alaska are adequately captured. This includes surveys, a twenty-four-hour hotline, focus groups, and advisory committees. Functional committees, with members made up of Alaska Native representatives, have also been established to respond to customer-owner feedback and ensure there is a clear mechanism to use the feedback to continuously improve the system of care.^{Footnote 136}

Through the Nuka System of Care and the emphasis on customer ownership and relationships, the Southcentral Foundation has directly contributed to a significant improvement in health outcomes, including a 42% reduction in emergency room use (illustrating a proactive approach to healthcare as opposed to reactive); a 36% reduction of days spent in hospital; a 75% reduction in staff turnover; a 25% increase in childhood vaccination rates; and 94% increase of patient reports of culturally safe experiences in healthcare.^{Footnote 137}

In addition to the initiatives highlighted above, interviews conducted with both internal and external partners during this evaluation also highlighted the following best practices in the areas of data sovereignty, relationship building, knowledge sharing and collaboration:

• The importance of data collection was specified as valuable in order to understand changes over time. In particular, supporting First Nations and Inuit data sovereignty is required to ensure information that is shared truly reflects First Nations and Inuit needs and priorities, including access to culturally safe health care.
• The value of building respectful and longstanding relationships with First Nations was repeatedly emphasized in interviews, along with a clear understanding of the department's role. It was regarded that two-way feedback facilitates an understanding of what aspects are working well for First Nations and Inuit and what is not.
• Building communication mechanisms and networks for First Nations and Inuit and ISC staff alike to share knowledge, best practices, and lessons learned was highlighted as valuable in supporting continued progress. Interviews also emphasized the role that effective documentation of knowledge by both ISC staff and personnel in First Nations health services plays in supporting knowledge transfer and building expertise.
• Breaking down barriers between services, sectors, organizations, and levels of government is key to promoting a more wholistic view of health care service delivery for First Nations and Inuit. As described in previous sections of this report, there are opportunities for ISC programs to be better integrated to address social determinants of health.