What we examined (see Focus of the audit)

Health Canada supports First Nations through various health programs based on the 1979 Indian Health Policy. Under these programs, the Department provides funding for the delivery of health services in remote First Nations communities, where individuals face special health challenges and have limited access to provincial health services. According to the Department, support to these communities extends to 85 health facilities, where health services are delivered through collaborative health care teams, led by approximately 400 nurses. These health facilities serve approximately 95,000 First Nations individuals.

This audit focused on whether Health Canada had reasonable assurance that eligible First Nations individuals living in remote communities in Manitoba and Ontario had access to clinical and client care services, and medical transportation benefits.

Why we did this audit

This audit is important because First Nations individuals living in remote communities face unique challenges in obtaining essential health services. They rely on the federal government’s support to access health services within their communities, or on federally supported transportation benefits to access health services outside their communities.

What we concluded

Overall, we concluded that Health Canada did not have reasonable assurance that eligible First Nations individuals living in remote communities in Manitoba and Ontario had access to clinical and client care services and medical transportation benefits as defined for the purpose of this performance audit.

What we found

Nursing stations

Overall, we found that Health Canada nurses working in nursing stations were properly registered with their provincial regulatory bodies, but only 1 of the 45 nurses in our sample had completed all five of Health Canada’s mandatory training courses that we selected for examination.

Health Canada acknowledges that its nurses sometimes work outside their legislated scope of practice in order to provide essential health services in remote First Nations communities. However, we found that Health Canada had not put in place supporting mechanisms that would authorize the nurses to perform activities outside their legislated scope of practice, such as medical directives to allow nurses to perform specific tasks under particular circumstances.

We also found that Health Canada had identified numerous deficiencies in nursing stations related to health and safety requirements or building codes. For a sample of 30 deficiencies, the Department could not provide evidence that the deficiencies had been addressed. Furthermore, one of the residences at a nursing station that we visited had been unusable for more than two years because the septic system had not been repaired. Consequently, medical specialists cancelled their visits to the community.

Lastly, we found that Health Canada had recently defined essential health services that should be provided in nursing stations. However, the Department had not assessed whether nursing stations had the capacity to provide these services nor had it informed First Nations individuals what essential services were provided at each nursing station.

These findings are important because First Nations individuals in remote communities should have access to essential health services from qualified nurses who have the authority to provide those services. Nursing stations that are non-compliant with health and safety requirements or building codes can put patients and staff at risk and may limit access to health services.

• Health Canada did not ensure that nurses had completed mandatory training courses

  Recommendation. Health Canada should ensure that its nurses working in remote First Nations communities successfully complete the mandatory training courses specified by the Department.

• Health Canada had not put in place supporting mechanisms for nurses who performed some activities beyond their legislated scope of practice

  Recommendation. Health Canada should ensure that its nurses are provided with appropriate supporting mechanisms that allow them to provide essential health services that are outside their legislated scope of practice.

• Health Canada could not demonstrate whether it had addressed nursing station deficiencies related to health and safety requirements or building codes

  Recommendation. Health Canada should work with First Nations communities to ensure that nursing stations are inspected on a regular basis and that deficiencies related to health and safety requirements or building codes are addressed in a timely manner.

  Recommendation. Health Canada should work with First Nations communities to ensure that new nursing stations are built according to applicable building codes.

• Health Canada had not assessed the capacity of nursing stations to provide essential health services

  Recommendation. Health Canada should work with First Nations communities to ensure that nursing stations are capable of providing Health Canada’s essential health services.

  Recommendation. Health Canada should work with First Nations communities to communicate what services each nursing station provides.

Medical transportation benefits

Overall, we found that medical transportation benefits were available to registered First Nations individuals in the Indian Registration System, but those who had not registered may be denied access to these benefits. This is important because First Nations individuals who are denied access to medical transportation benefits may not be able to receive health services that are only available outside of their community.

We also found that Health Canada’s documentation concerning the administration of medical transportations benefits was insufficient. For example, there was lack of documentation to demonstrate that the requested transportation was medically necessary and to confirm that individuals attended the appointments for which they had requested transportation. Sufficient documentation is needed to document decision making and facilitate consistent delivery of services and benefits.

• Some First Nations individuals had not registered and were therefore ineligible for Health Canada`s medical transportation benefits

  Recommendation. Health Canada should work with First Nations communities, and Aboriginal Affairs and Northern Development Canada, to facilitate the registration of First Nations individuals.

• Health Canada did not sufficiently document the administration of medical transportation benefits

  Recommendation. Health Canada should maintain sufficient documentation to comply with the Treasury Board’s 2009 Directive on Recordkeeping and to demonstrate that medical transportation benefits are administered according to Health Canada’s 2005 Medical Transportation Policy Framework.

Support allocation and comparable access

Overall, we found that Health Canada did not take into account the health needs of remote First Nations communities when allocating its support. Taking into account communities’ health needs is important because it would help to ensure that available departmental support is allocated to areas with the greatest needs and that it contributes to improving the health status of First Nations.

We also found that Health Canada had not implemented its objective of ensuring that First Nations individuals living in remote communities have comparable access to clinical and client care services as other provincial residents living in similar geographic locations. Health Canada needs to know whether its support is providing comparable access so it can make adjustments that may be necessary to ensure its support provides access to an appropriate level of service.

• Health Canada did not take into account community health needs when allocating its support

  Recommendation. When allocating nursing staff levels and other support, Health Canada should work with First Nations communities and take into account their health needs.

• Health Canada did not compare access to health services in remote First Nations communities to access in other remote communities

  Recommendation. Health Canada should work with First Nations communities, provinces, and health service providers to ensure that First Nations individuals living in remote communities have comparable access to clinical and client care services as other provincial residents living in similar geographic locations.

Coordination of health services among jurisdictions

We found that committees comprising representatives of Health Canada and other stakeholders in Manitoba have not proven effective in developing workable solutions to interjurisdictional challenges that negatively affect First Nations individuals’ access to health services. In Ontario, two formal coordinating committees were either recently established or in the process of being established but it was too early to assess their effectiveness.

This is important because the lack of coordination among jurisdictions can lead to inefficient delivery of health care services to First Nations individuals and to poorer health outcomes for First Nations individuals. Workable solutions are needed to improve accountability and ensure that individuals in remote First Nations communities have comparable access to health services.

• Committees to resolve interjurisdictional challenges have generally not been effective

  Recommendation. Working with First Nations organizations and communities, and the provinces, Health Canada should play a key role in establishing effective coordinating mechanisms with a mandate to respond to priority health issues and related interjurisdictional challenges.

Entity Responses to Recommendations

The audited entities agree with our recommendations, and have responded (see List of Recommendations).

Related Information

For more information

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