What we examined (see Focus of the report)

We undertook this work to inform Parliament about how efforts by British Columbia First Nations and Health Canada overcame the structural impediments identified in the 2011 June Status Report of the Auditor General of Canada, Chapter 4—Programs for First Nations on Reserves, as they established the First Nations Health Authority in British Columbia.

As part of this work, we identified success factors that, in our opinion, helped to overcome the structural impediments we had identified in our 2011 audit and that helped to establish the First Nations Health Authority. Our identification of success factors is not meant to be prescriptive, but it may be useful to First Nations and other governments that are considering similar transfers. Although we did not formally examine the Province of British Columbia’s activities as part of the report, we noted its significant and ongoing support in the process, and have referred to the Province’s contribution in this report.

Why we did this report

This report includes a study that covers the period from 2005 to Health Canada’s finalization of the transfer of control to the First Nations Health Authority in 2013. During work on the study, we added to the scope by conducting an audit of selected aspects of the Authority’s accountability and governance framework. We examined its early implementation of that framework, over the period from 2013 to 2015. We conducted this audit in response to an anonymous document we received, making allegations against the Authority in relation to its accountability and transparency. The objective of this audit was to determine whether the First Nations Health Authority had established and implemented selected elements of an accountability and governance framework.

What we concluded

Efforts by Health Canada to work with First Nations in British Columbia to establish the First Nations Health Authority represented a different approach to resolving a long-standing health issue: the poorer health outcomes of First Nations people in British Columbia than those of other residents. All parties—Health Canada, First Nations, and the Province of British Columbia—recognized from the start that they would have to work together, and in a different manner than before, if they hoped to make meaningful strides toward improving First Nations health.

The hard work is only beginning. Improving health outcomes is not easy. However, as other governments and First Nations from across the country consider how to improve programs and services to First Nations, we note that taking stock of what has worked, and why it has worked, may be an important place to start. This assessment will be particularly important as the Authority embarks on plans to expand its activities.

Our study noted that the sustained commitment of leaders from British Columbia First Nations, the Government of Canada, and the Government of British Columbia was important to establishing the First Nations Health Authority, as was the identification of a single First Nations point of contact to negotiate with the federal and provincial governments. Furthermore, the Tripartite Framework Agreement on First Nation Health Governance and the Canada Funding Agreement addressed challenges related to

• establishing service levels,
• legislation to guide activities and the need to explore how legislation may change as circumstances evolve,
• a long-term funding mechanism, and
• support for local capacity for program delivery in communities.

Our audit concluded that the First Nations Health Authority did not establish and implement selected elements of an accountability and governance framework. Although the Authority had policies in place to guide its operations, there were some weaknesses in the Authority’s policies that we examined, and a lack of guidance surrounding how they were to be implemented. We also concluded that the Authority was not fully complying with some of its existing policies. As the Authority shifts from a period of transition to the delivery of programs and services, its success will depend on its ability to demonstrate that it has the accountability and governance framework in place and on its compliance with its policies.

What we found

Establishing the First Nations Health Authority

Overall, British Columbia First Nations, Health Canada, and the Province of British Columbia successfully collaborated over a period of 10 years to develop a new model for providing health services to First Nations in British Columbia. Specifically, efforts to establish the Authority were facilitated by

• a sustained commitment of British Columbia First Nations leadership, and of leaders from the Government of Canada and the Government of British Columbia;
• a single British Columbia First Nations point of contact to negotiate with the federal and provincial governments; and
• the Tripartite Framework Agreement on First Nation Health Governance and the related 10-year Canada Funding Agreement that addressed challenges related to the four structural impediments we identified in the 2011 June Status Report of the Auditor General of Canada, Chapter 4—Programs for First Nations on Reserves: the lack of clarity about the type and level of services the federal government supports; the absence of a legislative or regulatory framework for programs to support First Nations communities; the absence of an appropriate funding mechanism for programs delivered in communities; and the absence of organizations to support local service delivery.

• Sustained commitment of leaders was critical to establishing the Authority

• First Nations identified a single point of contact, which facilitated negotiations with other levels of government

• The agreement establishing the First Nations Health Authority addressed challenges related to structural impediments that had affected service delivery

Establishing an accountability and governance framework at the First Nations Health Authority

Overall, we found that the First Nations Health Authority had established an accountability and governance framework to guide its operations and to promote transparency and accountability. This framework included a range of policies setting out how the Authority was to be managed. However, we found gaps in the policies we examined, pertaining to conflict of interest, recruitment, personnel security, administrative investigations, financial information and disclosure, and employee relocation. We also found that the Authority’s guidance on implementing these policies was limited. In our examination of the Authority’s response to allegations made against it in relation to its accountability and transparency, we found that the Authority complied with its policy on conflict of interest. However, it did not fully comply with requirements set out in its policies on investigating misconduct and on staffing positions on the basis of merit. We also found that justifications for the considerable variation in allowances provided in senior management employment agreements were not documented.

This is important because a sound accountability and governance framework would allow the Authority to demonstrate that it is conducting its operations in keeping with its obligations set out in the Tripartite Framework Agreement on First Nation Health Governance, and with its obligations to British Columbia First Nations, its Board of Directors, the provincial health care system, and the federal and provincial governments.

• There were some weaknesses in the Authority’s policies that we examined

  Recommendation. The First Nations Health Authority should review the policies that form its accountability and governance framework, to ensure that they are consistent with requirements set out in the Tripartite Framework Agreement on First Nation Health Governance and comparable to those of similar publicly funded organizations. The Authority should also develop specific guidance on how each policy is to be followed and monitored.

• The Authority did not comply fully with all of the policies we examined

  Recommendation. The First Nations Health Authority should review the conflict of interest raised by the allegation, as well as any other actual or perceived conflicts of interest regularly, to determine whether they are adequately mitigated. It should also regularly report the results of its reviews to the Board of Directors.

  Recommendation. The First Nations Health Authority should ensure that all allegations of workplace misconduct are investigated in accordance with its Administrative Investigations Policy, that adequate steps are taken to investigate them according to pre-established guidelines, that there is adequate documentation of investigations, and that corrective actions are taken when necessary.

  Recommendation. The First Nations Health Authority should ensure that it has documentation to demonstrate that the most qualified candidates are hired, in keeping with the requirements set out in the Tripartite Framework Agreement on First Nation Health Governance.

  Recommendation. The First Nations Health Authority should finalize its remuneration policy for senior executives and bring it before the Board of Directors for its approval.

• The Authority was taking steps to strengthen accountability and governance

  Recommendation. Health Canada should work with the First Nations Health Authority to ensure that a sound accountability and governance framework is established and implemented, in keeping with requirements set out in the Tripartite Framework Agreement on First Nation Health Governance.

Entity Responses to Recommendations

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

Related Information

Report of the	Auditor General of Canada
Type of product	Performance audit / Study
Topics	Aboriginal Affairs Health Provinces and Territories
Audited entities	First Nations Health Authority Health Canada
Completion date	21 August 2015
Tabling date	2 February 2016
Related audits	Chapter 4—Programs for First Nations on Reserves, 2011 June Report of the Auditor General of Canada

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