Question Period Note: On-Reserve Healthcare Services

• The Government of Canada is committed to continuing to
improve access and the quality of healthcare services in
Indigenous communities while supporting devolution of control
of service to Indigenous communities.
• Indigenous Services Canada supports on-reserve healthcare in
areas such as primary care, public health, and home and
community care in collaboration with Indigenous communities.
• Healthcare services are either funded for direct service delivery
by Indigenous communities or provided by ISC employees in
areas where access to provincial and territorial services are
limited.

The provision on healthcare on-reserve is derived from the 1979 Indian Health Policy which
aimed to achieve an increasing level of health in Indian communities, generated and maintained
by Indigenous communities themselves.
This aligns with the current vision of ISC to support and empower Indigenous peoples to
independently deliver services and address the socio-economic conditions in their communities.
Primary care services are delivered under the Clinical and Client care program and include
emergency services (triage, life sustaining care and emergency evacuation services), urgent
care (assessment and treatment of new or worsening symptoms), and non-urgent care (routine
checkups, maternal-child health, chronic disease prevention and management, etc.)
Community Oral Health Services focus on the prevention of dental disease at an early age and
the promotion of good oral health practices and also include clinical care, emergency services.
First Nations and Inuit Home and Community Care Program
A FNIHB flagship program, the First Nations and Inuit Home and Community Care Program
(FNIHCC) provides a continuum of home and community health care services that are
comprehensive, culturally sensitive, and accessible, and that respond to the unique health and
social needs of First Nations and Inuit.
The home care program is a coordinated system of health services that enable First Nations
and Inuit of all ages with disabilities, chronic or acute illnesses, and the elderly, to receive the
care they need in their homes and communities. Co-designed in 1999, FNIHCC works with
First Nations and Inuit partners to provide core home and community care services. It is
provided primarily through contribution agreements with First Nation and Inuit communities and
Territorial Governments and strives to enhance, or be the sole provider of home and community
care services offered to other Canadian residents in similar geographical areas. Home and
Community Care is delivered primarily by home care registered nurses and trained and certified
personal care workers. Service delivery is based on assessed need by a nurse, and follows a
case management process.
The objectives of the FNIHCC program are to provide access to a range of home and
community care services to First Nations or Inuit community members living in a First Nations or
Inuit community; assist First Nations and Inuit living with chronic and/or acute illness in
maintaining optimum health, well-being and independence in their homes and communities;
ensure that all clients with an assessed need for home care services have access to a
comprehensive continuum of services within the community, where possible; assist clients and
their families to participate in the development and implementation of the client’s care plan to
the fullest extent possible and to utilize community support services where available and
appropriate in the care of clients; and continue to build the capacity within First Nations and Inuit
communities to facilitate the delivery of home care services that enable program monitoring,
evaluation, research, and the definition of best practices.
Joyce’s Principle
Joyce's Principle aims to guarantee to all Indigenous Peoples the right of equitable access to
social and health services, as well as the right to enjoy the best possible physical, mental,
emotional and spiritual health. In the spirit of Joyce’s Principle, the Government is treating anti-
Indigenous racism in health care as an urgent priority and has taken action and continues to
take action to address this issue.
The final report following the Coroner’s inquest regarding Joyce Echaquan’s death was released
on October 1, 2021. It concluded that the racism and prejudice Joyce Echaquan was subjected
to contributed to her death and made several recommendations. While none were directed
towards the Government of Canada, some specific recommendations include:
o Recognize the existence of systemic racism within our institutions and make a
commitment to contribute to its elimination.
o Ensure the effective integration of the Atikamekw liaison officer into the hospital, in
particular by involving them with care teams.
o Include in the school curriculum training on the care of Indigenous patients that takes
into consideration the realities of Indigenous communities.
o Establish with Indigenous communities a greater offer of internships for both nurses and
medical residents
In August 2021, Indigenous Services Canada and Health Canada released the federal response
to addressing anti-Indigenous racism in Canada’s health systems: https://www.sacisc.
gc.ca/eng/1628264764888/1628264790978.
Birth Alerts
CBC Article on May 15, 2023 (https://www.cbc.ca/news/canada/ottawa/birth-alert-the-ottawahospital-
continue-after-october-2020-1.6835776):
• Birth alerts are notifications given to hospitals regarding unborn children who are
deemed “high risk” by child welfare agencies. Health-care providers are then required to
alert welfare authorities when the pregnant person comes to seek medical care or
deliver their baby. In turn, the newborn children are at risk of directions being taken,
including medical testing, preventing the child from leaving the hospital with their
parent(s), or being removed from their parent(s) at birth.
• This alert system was stopped by Ontario government in October 2020, but Quebec
child welfare agencies continued to send alerts to Ottawa hospitals. CBC reported that
the Ottawa Hospital received 298 birth alerts from October 2020 onwards, although they
were not acted upon, according to the hospital. Victims who received birth alerts report
not knowing the reasons why the child welfare agencies issued alerts on them. An
Indigenous Ottawa doula reported having clients in Ottawa that had experienced birth
alerts recently in 2023 and felt targeted and unsafe.
Distinctions-based Indigenous Health Legislation
The 2022 mandate letter for the Minister of Indigenous Services commits to "fully implement
Joyce's Principle and ensure it guides work to co-develop distinctions-based Indigenous health
legislation to foster health systems that will respect and ensure the safety and well-being of
Indigenous Peoples."
The 2020 Fall Economic Statement announced an initial investment of $15.6 million over 2
years, starting in 2021 to 2022 to support the co-development of distinctions-based+ health
legislation with First Nations, Inuit and the Métis Peoples.
From Winter 2021 to Fall 2022, regional and national First Nations, Inuit, Métis, and
Intersectional Partners led numerous engagements within their communities on the vision for
distinctions-based Indigenous health legislation. A national summary report, What we heard:
Visions for Distinctions-based Indigenous Health Legislation, was published in January 2023.
The report summarizes the input the Government of Canada has received to date from
Indigenous Peoples about their vision for what to include in distinctions-based Indigenous health
legislation to improve access to high-quality, culturally-relevant, and safe health services.
From Fall 2022 to June 2023, ISC launched distinctions-based+ co-development processes,
which focused on translating what was heard through engagement into proposed legislative
options. In total, 14 co-development tables were launched with First Nations, Inuit, Métis, and
intersectional partners.
Participation in the co-development tables provided an opportunity to help identify the federal
legislative measures necessary for supporting Indigenous-led approaches to improve health
equity.
On August 29, ISC released a “Key Legislative Elements” document, outlining the proposed
preambular recognitions, purpose, and measures for the bill, for feedback from partners by
September 22. From August 29 until September 22, ISC facilitated 27 discussions and, as of
October 20, have received 39 written submissions from partners.
Feedback from discussions and written submissions regarding the content of the “Key
Elements” document as well as the co-development process overall is currently being reviewed
to inform the fall cabinet submission. ISC will continue to share information on next steps for
Indigenous health legislation with First Nations partners as soon as there is a clear direction for
the future of the initiative.

Specific situation regarding nurses in Nunavik
Since the summer 2022, several media have been reporting on the alarming situation in
Nunavik concerning the lack of nursing staff and the disruption of services to the Inuit
population.
ISC does not fund Clinical and Client Care nursing services in Nunavik because since 1975, the
provision of health and social services in Nunavik has been in accordance with the James Bay
and Northern Quebec Agreement. This agreement led to the transfer, from the federal
government to the provincial government, of most of the responsibilities concerning services for
Inuit communities, including notably health and social services.
The Quebec government has implemented several measures since the summer 2022 to
address the nursing shortage in Nunavik, including improved attraction and retention bonuses,
an increase in the number of leaves granted to staff working in Nunavik, and easier access to
"northern leave", which allows a nurse to temporarily leave her position in the Quebec
healthcare network to work in Nunavik.
Meanwhile, ISC provides funding to support the delivery of health programs and services in
Nunavik which were created after the James Bay and Northern Quebec Agreement signature,
such as promotion and prevention programs. Clinical care programs such as nursing in
emergency and critical care settings are not eligible for ISC funding, with the exception of home
care services, because this program was created after the Convention was signed.
In addition, ISC collaborates to the TB eradication plan upon request and has sent nurses from
the department to Nunavik to help fight tuberculosis in Inuit villages.
The Nunavik Regional Board of Health and Social Services informed ISC of the difficulty in
retaining and recruiting nurses due to the lack of available housing and difficult working
conditions. The lack of manpower and the exorbitant cost of construction in the North are major
obstacles to the development of additional staff housing. Local health professional or nursing
staff with Inuit background are rare.
The Nunavik Regional Board of Health and Social Services and ISC are currently exploring
various options to assist in nursing recruitment, including the use of the Nunavik Board's surplus
from ISC unspent funds.

If pressed on primary healthcare services
• Healthcare services are provided in 79 remote and isolated
nursing stations, two hospitals, community health centers and
treatment centers in Indigenous communities across Canada.
• Community based, on-reserve oral health services include the
Community Oral Health Services, including the Children’s Oral
Health Initiative and dental therapy services.
• The First Nations and Inuit Home and Community Care Program
(FNIHCC) is a mostly transferred program delivered by First
Nations to First Nations people on reserve, and to Inuit by P/T’s.
• The program delivers a suite of services to people with an
assessed health needs including children, people with
disabilities, elderly people, people with chronic and acute
illnesses, and people on palliative and end of life care.

Public Health services
If pressed on Mental Wellness Services
• The Government of Canada has made significant recent
investments to improve mental wellness in Indigenous
communities, with approximately $650 million in 2022-23.
• These investments are flexible to meet the immediate mental
wellness needs of communities by supporting Indigenous-led,
culturally-relevant community-based mental wellness
promotion, on-the-land initiatives, suicide prevention, life
promotion, crisis response, and substance use treatment and
prevention services in Indigenous communities.
• This funding also supports the provision of essential cultural,
emotional and mental health supports to Survivors of Indian
Residential Schools and Federal Indian Day Schools and
families of former students, as well as those affected by the
issue of Missing and Murdered Indigenous Women, Girls, and
2SLGBTQI+ people.

If pressed on Healthy Child Development
• The Healthy Child Development (HCD) suite of services support
healthy pregnancies, births, and child development in First
Nations and Inuit communities through various programs
• These programs include Maternal Child Health, Canada Prenatal
Nutrition (First Nations and Inuit Component), Indigenous
Midwifery, Aboriginal Head Start on Reserve, and Fetal Alcohol
Spectrum Disorder.
• These services aim to improve health outcomes for First Nations
and Inuit infants, children, youth, families (including pregnant
people) and communities through access to supports with areas
of focus that include:
o pre- and postnatal care and supports;
o pre-conception and reproductive health;
o nutrition;
o early literacy and learning; and,
o physical, emotional and mental health.

If pressed on Indigenous Early Learning and Child Care
(Interdepartmental Initiative)
• The Government of Canada jointly released the co-developed
Indigenous Early Learning and Child Care (IELCC) Framework in
September 2018 with the Assembly of First Nations, Inuit Tapiriit
Kanatami and the Métis National Council.
• This framework works to strengthen early learning and child
care programs and services for Indigenous children and families
across Canada.
• The IELCC Framework reflects the unique needs and cultures of
First Nations, Inuit and Métis and sets a vision for happy and
safe Indigenous children and families, strong cultural identity,
and a comprehensive and coordinated system that is anchored
in self-determination, centered on children and grounded in
culture.

If pressed on Environmental Public Health
• The Environmental Public Health Services team works with First
Nations communities South of the 60° parallel to identify and
prevent risks that could negatively impact the health of people in
both the natural and built environment, such as drinking water,
food safety, housing, and public facilities.
• Most of these services are provided by Environmental Public
Health Officers, who are certified public health inspectors, and
who are employed by Indigenous Services Canada or by First
Nations, tribal councils and other organizations.
• North of the 60° parallel, Environmental Public Health Services
are delivered by the territorial governments.

If pressed on Healthy Living
• The Government of Canada funds and supports a suite of
culturally relevant community-based health promotion and
disease prevention programs and services in First Nations and
Inuit communities.
• Funded programs, services, initiatives and strategies are
directed at promoting healthy behaviours and creating
supportive environments in the areas of
o healthy eating
o physical activity
o food security
o injury prevention
o commercial tobacco use prevention and cessation,
o and chronic disease prevention and screening.
• Communities determine which activities to undertake based on
their own unique needs and priorities.

Anti-Indigenous Racism in healthcare
If pressed on Joyce’s Principle
• Our Government is fully committed to implementing Joyce's
Principle and supporting initiatives aimed at combating anti-
Indigenous racism in health systems across the country.
• Joyce’s Principle aims to guarantee to all Indigenous people the
right of equitable access, without any discrimination, to all
social and health services, as well as the right to enjoy the best
possible health.
• Since 2021, the Manawan Atikamekw Council has set up the
Joyce’s Principle Office which carries out projects to improve
equitable access to health and social services for Indigenous
Peoples.
• The implementation of Joyce’s Principle is ongoing and relies
on linkages to investments in addressing anti-Indigenous
racism, the Indigenous Health Equity fund, and the codevelopment
of Indigenous Health Legislation.

If pressed on funding for Joyce’s Principle
• In response to the death of Joyce Echaquan, Budget 2021
provided $126.7 million over three years (2021-2024) to take
action to foster health systems free from racism and
discrimination where Indigenous Peoples are respected and
safe.
• In addition, Indigenous Services Canada (ISC) provided $2
million to the Atikamekw Nation and Manawan First Nation to
support the implementation of Joyce's Principle.

If pressed on Birth Alerts
• The Government of Canada recognizes that the presence of birth
alerts disproportionately affected Indigenous mothers.
• Birth alerts are supposed to have ceased in all provinces as of
April 2023, however more work needs to be done to implement
Joyce’s Principle and address the systemic racism that still
exists in health systems as well as in Child and Family Services.
• We are encouraged that all provinces and territories have now
formally abolished birth alerts and we support the provinces in
ensuring equitable services where Indigenous Peoples can be
respected and safe.

If pressed on Distinctions-based Indigenous Health Legislation
• In 2021, our government committed to co-developing
distinctions-based+ Indigenous health legislation to improve
access to high-quality, culturally relevant, and safe health
services, with First Nations, Inuit, Métis, and Intersectional
partners.
• Discussions on a “Key Legislative Elements” document took
place from August 29 until September 22, during which ISC
hosted multiple discussions to elicit feedback on the proposed
legislative measures and received over 30 written submissions
from partners across distinctions.
• The extensive feedback received from Indigenous partners is
currently being reviewed. Indigenous Services Canada
continues to remain dedicated to information sharing with
Indigenous partners on the way forward for Indigenous health
legislation.

If pressed on non-Insured Health Benefits
• The Non-Insured Health Benefits (NIHB) Program provides
clients (registered First Nations and recognized Inuit) with
coverage for a range of health benefits.
• Benefits under NIHB include prescription drugs and over-thecounter
medications, dental and vision care, medical supplies
and equipment, mental health counselling, and transportation to
access health services not available locally.
• The NIHB Program is universal, covering all eligible First
Nations and Inuit clients regardless of age, income, location (in
or outside communities) or other proxy measures of socioeconomic
need; unless otherwise covered under a separate
agreement with federal or provincial governments or through a
separate self-government agreement.

If pressed on dental benefits under the Non-Insured Health
Benefits program
• The NIHB Program covers eligible First Nations and Inuit clients
unless otherwise covered under another plan or program or
under a separate agreement (such as a self-government
agreement).
• The NIHB dental benefit covers a broad range of dental services
including:
o diagnostic (i.e. exams and x-rays),
o preventive (i.e. sealants),
o restorative (i.e. fillings),
o endodontic (i.e. root canals),
o periodontal (i.e. scaling),
o removable prosthodontic (i.e. dentures),
o oral surgery (i.e. extractions),
o orthodontic (i.e. braces) and
o adjunctive (i.e. sedation) services.
• The NIHB Program also provides coverage for medical
transportation benefits, to assist eligible clients to access
health services, including dental services, that are not available
locally.

If pressed on dental benefits under the Non-Insured Health
Benefits Program during the pandemic
• Early in the pandemic, dental services across the country were
limited to emergent and urgent needs only, following guidance
from provincial/territorial dental regulators and public health
authorities.
• As dental regulatory guidance evolved, ISC began to safely
increase service levels back in communities. Resumption of
services was guided by community leadership and the ability to
ensure all the interim infection prevention and control guidelines
could be adhered too.
• Throughout the COVID-19 pandemic, the NIHB program has
remained available and has continued to provide coverage for
dental services, as well as medical transportation expenses
(including transportation, meals and accommodations), for
eligible patients needing to travel out of community to access
dental services.

If pressed on Nursing Shortage
• Indigenous Services Canada recognizes working conditions for
Nurses has a direct impact on the care received by clients.
• Nurses are the fulcrum of healthcare delivery to many First
Nation and Inuit communities across Canada, where access to
provincial services are not readily available.
• We are taking active measure to improve the working conditions
of nurses by introducing various improvements and initiatives.

If pressed on Nursing shortages in Nunavik
• Indigenous Services Canada does not fund Clinical and Client
Care nursing services in Nunavik as the provision of health and
social services is under provincial jurisdiction since 1975
(James Bay and Northern Quebec Agreement).
• Nunavik Regional Board of Health and Social Services is
therefore responsible for recruitment & retention of Nursing staff
and their working conditions
• Nunavik Regional Board of Health and Social Services is going
through major Nursing shortage and is currently exploring
various options to face the nursing recruitment challenge.