HEAL Committee Meeting

STANDING COMMITTEE ON HEALTH

COMITÉ PERMANENT DE LA SANTÉ

EVIDENCE

[Recorded by Electronic Apparatus]

Thursday, November 6, 1997

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[English]

The Chair (Ms. Beth Phinney (Hamilton Mountain, Lib.)): I call the meeting to order.

Pursuant to Standing Order 108(2), we will continue our consideration of chapter 13 of the October 1997 Report of the Auditor General of Canada on Health Canada—first nations health.

Before we start and before I introduce the witnesses, I would like to make you aware of the fact that we have a little bit of business to do at the close of the meeting. I will be calling the witness part of the meeting to an end at 12.20 p.m., and then we'll have the business part.

We're very pleased that we have representation from the Office of the Auditor General on such short notice. We do not have the Auditor General, which I guess is obvious, but we have the assistant auditor general, Maria Barrados.

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Before I allow Madame to introduce the person who is with her, I will remind you of our process for questioning. We will have the official opposition for five minutes, the second opposition for five minutes, five minutes for the government side, and then back and forth for five minutes.

Would you like to introduce the person with you?

Ms. Maria Barrados (Assistant Auditor General, Office of the Auditor General of Canada): Thank you, Madam Chair.

I have with me this morning Ronnie Campbell, who is the auditor responsible for the audit of the first nations health. We're very happy to be able to appear before your committee to talk about the audit report that was tabled in October on first nations health.

As Parliament's auditors, we examine the operations and management of Health Canada's programs. In 1995 we reported on the results of an audit of the management change initiative in the Health Protection Branch. We will be following up on this audit as part of the new work we are starting at the branch.

[Translation]

In our audit of First Nations Health, we examined whether the Department manages First Nations health programs in an efficient and effective manner, and whether an appropriate accountability framework is in place for the transfer of health services to community control.

As this Committee is well aware from its work on the health of Aboriginal people in the last Parliament, there are glaring differences in health status between the First Nations population and the Canadian population overall. A multitude of factors influence health and many players are involved in the delivery of a variety of health services and programs.

Expenditures for the health services delivered to the First Nations by Health Canada amounted to about $1 billion in 1995-96. Community health programs and transfer agreements accounted for almost $450 million, while non-insured health benefits totalled approximately $516 million.

Community health programs and non-insured health benefits were initially delivered directly by the Department's Medical Services Branch. For several years Health Canada has been moving out of direct health care delivery. At present, most community health programs are delivered through arrangements with First Nations under agreements with them. Twenty-seven percent of First Nations have signed transfer agreement, 13% an integrated agreement, and 60% separate contribution agreements. The Department remains accountable for the programs but its involvement and operational knowledge will vary with the nature of the agreement.

[English]

Our audit found that some improvement is needed in the management of community health programs delivered through separate contribution agreements and transfer agreements. Madam Chair, I'd like to go over these findings briefly.

Many of the community health programs overlap and they are trying to address the same problems. This causes potential duplication and confusion in administering them as different programs. In addition, overlaps in programs increase the difficulty of attributing results to a specific program.

Contribution agreements are not only a means of transferring funds but also an agreement on the provision of health services to the first nations population. Not enough attention is given to that portion of the agreement dealing with the provision of services. In most cases the agreements are not clear about specific objectives and activities that first nations will undertake.

Further, in two-thirds of the contribution agreements we examined the department did not have the required information it needs to monitor agreements effectively and to help first nations build their capacity and improve their management practices. The department is not fulfilling its responsibilities to manage in a way that helps first nations establish programs and services likely to improve their health.

A sound framework has been developed for the transfer of some health programs to community control. It has allowed first nations to start managing their own health programs. Improvements are required, however, particularly in the area of performance reporting and measures of change to health. These are needed to meet the accountability obligations of first nations and the department and also to improve the programs and services.

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The non-insured health benefits program provides a range of health benefits and services that supplement provincial and third-party health insurance programs.

The audit identified significant weaknesses in the management of pharmacy, dental, and medical transportation benefits. In particular, there is an urgent need to address the abuse of the prescription drug system.

[Translation]

The program lacks adequate systems and controls to counter abuse of pharmacy benefits, allowing clients to access extremely high levels of prescription drugs. Although Health Canada has been aware of the problem of prescription drug misuse for almost 10 years, action to intervene has been slow.

There are few studies available that provide estimates of how widespread this problem is. In fact, there were no available data that could provide an accurate comparison with the general Canadian population.

[English]

The problem has a terrible human cost. There have been numerous reports of prescription drug addiction and prescription drug-related deaths of first nations individuals in several provinces.

In an attempt to address program weaknesses Health Canada is going to implement a point-of-service system for its pharmacy benefits by the end of 1997. The department has also announced that a new contract for the processing of pharmacy and dental claims has been awarded to a different contractor.

The department is committed to making changes and to tightening up the controls in the new contract. It is vital to put proper controls in place to ensure appropriate use of benefits and prudent use of public funds.

Finally, planning is under way to transfer the non-insured health benefits program to first nations control. We believe there is a need to resolve systematic problems before the transfer of the program.

Madam Chair, that concludes my opening statement. I'd be pleased to answer your committee's questions.

The Chair: Thank you very much.

Mr. Elley.

Mr. Reed Elley (Nanaimo—Cowichan, Ref.): Thank you very much for coming and addressing our committee today and taking our questions.

I have eight children, three of whom are aboriginal. Because of that, of course, they're outside of the system you describe. I'm very concerned about the drug abuse problem you are signalling here.

I'm wondering if you can tell us from your findings whether or not you see a very direct correlation between the mismanagement of the drug program under NIHB and the kind of rising drug abuse that we see generally in the native population today.

Ms. Maria Barrados: As the auditors of Parliament, we look at the programs delivered by Health Canada. That's the scope of our work.

We looked at two parts of the programs. One was the community health programs that deal with problems of drug abuse. Our concern on that side was that there wasn't enough information to know whether or not these programs were working very well.

The problem on the other side, on the non-insured health benefits, was looking specifically at prescription drugs and the control on prescription drugs. We're not really in a position to draw the kind of linkage you're asking about.

Mr. Reed Elley: Do you see that there are real weaknesses? Obviously you do.

You see real weaknesses in the way this particular service is delivered to our native peoples. Where are we pointing the finger at for this problem? Where does the real problem lie? Does it lie with the way in which government handles it? Now that it's being slowly turned over to our native people, where does the gap lie in dealing with this problem?

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Ms. Maria Barrados: If we're talking about the non-insured health program, which is the prescription drugs, that's a problem that clearly is under the management responsibility of Health Canada, but the problem isn't entirely under the control of Health Canada. When we did this work, we went to some efforts to identify the areas of risk. There are a number of areas of risk here.

There's the prescribing practices of doctors, and that is something not under the control of Health Canada, although Health Canada has taken steps to send warnings to doctors. There is the dispensing of the prescriptions by pharmacists. Now that's an area in which Health Canada can do more, and they are going to be doing it. There is also the first nations people themselves. There is a multitude of players here.

We find risk elements in all of them, but at the end of the day we felt Health Canada could be doing a lot more to intervene. The big message we are stressing is that more should be done to stop what we feel is abuse of the system.

Mr. Reed Elley: Do you have any suggestions on the intervention?

Ms. Maria Barrados: Yes. Health Canada is now putting in place a point-of-service system, so when a first nations person goes to a pharmacy warning messages will come up. We support this initiative, and we're pleased to see that Health Canada is going to be doing it. We do have concerns that this be done in a timely manner, that the warning messages be strong, and that there be an evaluation.

More, too, needs to be done in the management of this system in terms of thresholds and audits. There are many areas. First nations peoples themselves should be contacted directly if they are exhibiting a pattern of drug use that seems unusual.

Mr. Reed Elley: Why is this taking so long? My colleague says that—

The Chair: We're going to our next questioner. Mr. de Savoye.

[Translation]

Mr. Pierre de Savoye (Portneuf, BQ): It is astounding to see how expensive and inappropriate is the health care provided to Aboriginals, and that the First Nations, particularly the young people, are in such a distressing state of physical and psychological health.

I was struck by a number of your comments, Ms. Barrados. First of all, in paragraph 10, you say: "The department is not fulfilling its responsibilities to manage in a way that helps First Nations...". You also say that "there is an urgent need to address the abuse of the prescription drug system". You add: "Although Health Canada has been aware of the problem of prescription drugs misuse for almost 10 years." Lastly you note that the department announced that a new contract has been awarded to a different contractor.

I'm going to put a very direct question to you. Are you in a position to tell us this morning that there was no racket among the various parties to encourage Aboriginal people to overconsume and thus put money in the pockets of those involved in the racket? Is this kind of racket still taking place? Are you in a position to tell us that there has never been a racket of this type?

[English]

Ms. Maria Barrados: Madam Chair, I'm not in a position to provide assurance one way or the other. When we do this audit work we look at the responsibilities of Health Canada and whether they are carrying out their responsibilities. We do point out drug use that is higher than one would expect. There are instances in which if the person obtaining these prescriptions took all of these drugs, that person would be, in the words of medical officers in the department, non-functioning. We don't do our audit work any further. We don't go into the communities or what people do with these prescriptions and all those other links. So I regret that I can't assure the committee one way or the other. The only thing I can say with confidence is there are patterns of drug use that is unacceptably high.

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[Translation]

Mr. Pierre de Savoye: Ms. Barrados, you say that Health Canada has been aware of this problem for about ten years and that it has taken some time to intervene. Why did Health Canada take time to intervene? What action has it undertaken and what does it expect to do in the coming months to deal with this significant problem?

[English]

Ms. Maria Barrados: One of the reasons we highlighted this distance of time was our concern that there wasn't the kind of intervention we felt necessary. Health Canada has undertaken a number of studies, they have put in place information systems, but our concern is there hasn't been the intervention we feel necessary to actually stop the dispensing of and the payment for drugs that do not seem to be going where they should be going and used in the manner they should be used. The kind of intervention we are suggesting is the kind of intervention that Health Canada is proposing, and that is a point-of-service drug system. The kind of intervention we are suggesting is that thresholds be clearly identified and that action be taken when any kind of prescription goes beyond that threshold.

In addition, we are recommending that more effort be made to work directly with first nations people who are getting these prescriptions filled. There can be a number of human tragedies here, and that's what the media reports suggest. We feel it is very important that contact be made with first nations people and that the resources in the community health programs be marshalled to assist people who have prescription drug abuse problems.

[Translation]

Mr. Pierre de Savoye: I know that a few years ago Canadians and Quebeckers complained that their physician would prescribe drugs to deal with almost any kind of problem. But they didn't do anything to get to the root of the problem. It was just a matter of take this pill and don't think about it.

Lots of people were encouraged...

[English]

The Chair: Could you ask your question quickly, please. Your time is up.

[Translation]

Mr. Pierre de Savoye: Are we facing the same kind of situation in the case of Aboriginals? Rather than dealing with their real problem are we simply giving them pills so they keep quiet? Is it not the same kind of situation?

[English]

Ms. Maria Barrados: We recognize that there are also problems of drug use in the Canadian population. It is a problem that goes beyond first nations, but in this case we audited the first nations health program and the responsibilities of Health Canada. We looked to see if there was comparative data. We could find no comparative data to give any clear picture of whether the situation for first nations was unusual compared with that of the other populations. We came to the conclusion that the numbers we were seeing were not acceptable, regardless of where they were. We also came to the conclusion there are concentrated instances of human tragedy such that an argument about relative numbers really didn't help address the specific problem. Something needed to be done.

[Translation]

Mr. Pierre de Savoye: Thank you, Ms. Barrados.

[English]

The Chair: Thank you very much. Mr. Myers.

Mr. Lynn Myers (Waterloo—Wellington, Lib.): I was interested in reading the Auditor General's report and about program overlap, duplication, and confusion and the lack of clear objectives in this whole area.

First, can you give me a sense of how things deteriorated to this level? I don't expect a long answer, but I'd like a sense of how it went.

Second, you talked about the Health Canada point-of-service system. In answer to another question you referenced the need for timeliness and an evaluation. I wondered whether you could elaborate on that.

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Third, it's outlined in your brief on page 4, number 17, “We believe that there is a need to resolve systemic problems before the transfer of the program.” I wonder if you could elaborate on exactly what you mean by that.

Thank you.

Ms. Maria Barrados: Madam Chair, I'll try to go through this quickly.

On the question about overlaps, when we looked at these programs it seemed to be a situation where there was an honest effort to address identified needs, but a program would be put in place and then another program put in place and then another program put in place, so there was a series of programs that ended up overlapping, but each one was decided in isolation.

Our recommendation in this case is that the department sit down with the Treasury Board to streamline this and tidy it up, because it's inefficient and it's very difficult for everyone to manage and attribute what you're accomplishing.

In terms of your second question, I believe you're talking about the non-insured health benefits in the point-of-service system. The department has agreed to put this system in place by the end of this year. That's a very tight timetable, given that the contractor is now being changed. We believe such a system is one approach to dealing with this problem. There is no perfect solution here, but this is one approach.

We caution, in our report, that the department would have to be vigilant, because its initial designs were based on warnings to pharmacists, and then pharmacists would have to make decisions to dispense or not. The department will be looking at that and strengthening the warning system. It will also be looking at the possibility of whether there should be some incentive or payment for not dispensing, because what is the pharmacist's interest in not dispensing when he or she forgoes a fee? The department said it will be monitoring that. It's extremely important that the department evaluate how well this is doing to make corrections as it goes along, because the intention is to put some control on this.

Mr. Lynn Myers: Is the resolution of the systemic problems inherent?

Ms. Maria Barrados: Right.

There is a desire on the part of the Government of Canada to transfer programs to the management of first nations, and that is occurring in the community health programs in a staged kind of manner. There is a desire to do that also for non-insured health programs. There are some proposals and a pilot being discussed. In our view, before these programs are transferred some of the problems should be fixed.

Mr. Lynn Myers: What are some of these problems? Can you elaborate?

Ms. Maria Barrados: We identified a number in terms of prescription drugs and the control of that system. There is now good progress being made on the dental side in looking at another way of providing that service need, as opposed to just a total amount. But there are also things that need to be done on transportation.

Mr. Lynn Myers: Thank you.

The Chair: Ms. Wasylycia-Leis.

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP): Thank you very much, Madam Chair.

Further to my colleague's comments, and with all due respect to my colleagues in both Reform and the Bloc, I think it would be a mistake to focus on the whole question of drug abuse in isolation of a much more deep-seated systemic problem.

First, I don't think it takes into account the question of the kinds of abuse that happen when you have people operating under a colonial system for so long. I don't think it takes into account the fact that there is some progress happening around this question of partnership with the aboriginal community in terms of the drug utilization review. So what is your perception of how that whole process is going?

My bigger question is with respect to recommendations from the Auditor General's report pertaining to this speedy transfer arrangement happening. For years now health needs have been identified. Nothing has really changed, and yet we appear to be moving rapidly toward having transfer agreements in place for both medical services and the non-insured benefit program in short order. In fact, framework agreements are supposed to be achieved by April 1, 1998. Yet my understanding is that the discussion between the first nations and Inuit and the department has not gone beyond the questions of cost management and savings management. It has yet to address the issues of health needs, health care rights, and capacity in aboriginal communities for training their own people to be able to deliver services and meet the needs of all of their community.

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Can I interpret the Auditor General's report to mean that you would in fact recommend that this process slow down; that there be a proper consultation process to take the pressure off the situation; that we stop the dump and run approach and allow for that open partnership to occur?

Ms. Maria Barrados: Madam Chair, we make a number of observations in the report with respect to transfer. The first is that there is a framework for transfer in place for the community health programs. We examined that framework, and we found that it's a very sound framework. That framework has all the elements that we would expect to have in such a framework for transfer.

What our observations are with respect to the framework are questions of implementation. You have a sound framework, but we felt there wasn't consistent follow-through on the implementation of that program, of that transfer framework. So you have a plan to transfer, and then you will have modifications made in subsequent agreements, but the plans aren't modified. There isn't sufficient follow-up on the reports coming out of these and the evaluations.

So our comment there is that there is a good framework, but more has to be done on the implementation of it.

There are two other points I would like to make. On the other side of the community health programs, the approach being taken is to transfer when ready. Our comments on the management of the contribution agreements are very much directed towards good delivery of these programs, but also towards delivering them in such a way that they build the capacity of the first nations to be able to move to transfer. That's a very important element of these contribution agreements.

At the end of the report, we make a note that a number of first nations told us they were concerned there was an attitude of dump and run. To them, that meant there wasn't this focus on building the capacity for them to be able to manage the programs themselves. At the end of the report, the department is making the commitment that this is not its approach. Its approach is to want to work with the first nations to build that capacity.

The Chair: You have one minute, so make it a short question.

Ms. Judy Wasylycia-Leis: I hear what you're saying, and I just wanted to follow up with my sense from the community, at least with respect to the non-insured health benefit.

There's real pressure on the communities to agree to a framework document for that area in short order. There are a couple of documents out in the field now, whereby the first nations and Inuit communities feel they have guns to their heads in terms of having their consultation process done and feedback in by the end of 1997, in order for this framework document to be completed for April 1, 1998. Those basic issues dealing with the roots of the problems and the fundamental health care needs of the first nations community are not being addressed. In fact, there is some pressure around the government saying to sign now, to move quickly, or the money won't be there down the road. There is a real concern about the capping of funds and the inadequacy to respond to growing health care needs in the first nations communities.

The Chair: You've used up your time and quite a bit more, but we can have a short answer.

Ms. Maria Barrados: There's no question that the status of first nations people is not to the level of the Canadian population.

In the work that we did, we did not see any instances of pressure on the non-insured health programs to put a framework in place for transfer. There were expectations, however, that the transfer would move faster than it has on the community health program side. I believe the department recognizes that it can only go at a certain pace.

The Chair: Mr. Thompson.

Mr. Greg Thompson (Charlotte, PC): Thank you, Madam Chair.

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Going back to the non-insured health benefits expenditures, I believe you had mentioned that presently they're managed by a company under contract to Health Canada. My questions are in respect to that contract and that company. Does that company do it for all of Canada, or just a specific area? How many years have they had that contract? What are the terms of that contract?

Obviously the contractor is required to establish audit procedures and to report to Health Canada. Specifically, they are to detect and resolve any of those delivery and overbilling irregularities. I know some of those irregularities and deficiencies were brought to the attention of the department as far back as 1993. To go back to the purpose of my questioning, then, it is simply to ask why the government would wait so long to respond while knowing full well that the problem existed at least in 1993, and most likely prior to that. If those problems are recognized, whose responsibility is it to carry out the correction of those problems? Were the contractors—the contracted auditing company, if you wish—living up to the terms of their contract? Were they reporting in the way in which they should have reported?

Ms. Maria Barrados: The contractor for non-insured health has been Liberty Health. We don't name the contractor, but I don't think it's any particular secret. Liberty Health and Blue Cross have carried out some of the contracts for non-insured health since about 1987, initially for the dental benefits, and then subsequently for the drug benefits. These are national companies. They are not small, regional companies.

The problem that we identified in the report about a very weak audit can be linked to a lot of vagueness that is actually in the contract in terms of the requirement for the type of work that should be done and the level of audit that should be done. The contractor felt it was living up to the terms of the contract. We were concerned that there wasn't enough clarity and specificity in that contract to make sure that the level of audit was done.

We have not seen the new contract, but there have been commitments made. We hope they will be followed through, and that there will be greater specificity in the new contract to do the required audit.

Mr. Greg Thompson: I have a supplementary, Madam Chair.

Going back to the terms of the contract, I believe it's a publicly tendered contract—and you can respond to that. If it is a publicly tendered contract, would not the conditions and terms of that contract be transparent at this point? I guess what we're looking at is transparency in the whole process. I find it hard to believe that with as many deficiencies in that contract as there appear to be, the level of efficiency in the audit, for example, is not something the government would be aware of long before that contract was submitted. It's been out there, as you say, dating back to 1987. Responding in terms of.... You know, we're not talking about minor players. We're talking about international corporations that actually bid on that. Could you respond in terms of the transparency in that process and the terms of that contract?

Ms. Maria Barrados: Madam Chair, perhaps I could ask Ronnie Campbell to give you some comments and an update on the contracting process, where they are with the new contract.

Mr. Ronnie Campbell (Director, Audit Operations, Office of the Auditor General of Canada): Thank you, Madam Chair.

Speaking briefly about the new contract, all we have seen of that was an announcement by the department on October 16, I believe, that the new contract had been awarded to another company, and that this contract would take effect next June. I believe Blue Cross and Liberty Health still have the contract just now, but the department has made commitments in that public statement, in that press release, saying that the new contract would include strengthened controls and strengthened processes for monitoring.

As far as the existing contract is concerned, as Madam Barrados has said, the wording in that contract was quite vague. It talked about an appropriate audit regime, but it didn't specify beyond that what level of risk the department was willing to accept in terms of the amount of testing or the degree of testing the company would carry out. It was quite vague. And we don't know what the new contract will include.

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The Chair: Ms. Caplan.

Ms. Elinor Caplan (Thornhill, Lib.): Thank you.

I would like to focus my questions on the drug system. I think it's reasonable to say that you could substitute the terms “seniors” or “social assistance recipients”, who are receiving drugs under any provincial program in this country, for the term “natives” and have the same results the auditors have found in the native health program. When you look at it, I think you have to distinguish between deliberate misuse or fraud and the inappropriate use and misuse as a result of systemic problems.

I'm pleased to hear that they're moving to a point-of-service system, because I think the goal of every one of the drug programs across this country—and I think the goal is shared by every member of this committee—must be optimal therapy and appropriate use of the drugs people need to make them well or keep them healthy. Therefore there has to be a focus on the outcomes of these programs.

My concern is that the systemic problems that exist today are not the problem of any one individual, whether it's the ministry, the doctors writing the prescriptions, the pharmacists who are dispensing them, or the individual who is in need of the drugs. In fact, it's the whole claims payment method, which creates a very perverse incentive as opposed to an incentive to achieve the goal of appropriate use of drugs.

I'm wondering whether the point-of-service system the ministry is contemplating is also considering any alternate payment methods that would change the incentive for counselling, advice, and compliance in its scheme, or whether it is just trying to make changes in the use of the new technologies to control, monitor, and evaluate. I think program design is a major part of the problem.

Ms. Maria Barrados: Madam Chair, I think some of those questions might be better put to the Department of Health in terms of the kinds of alternatives they examined in order to conclude that was the way they were going to go. I agree there are a number of elements here, which we raise in the chapter, that speak to program design but that will not necessarily be dealing with this. That includes some of the other players who are part of the system. That won't be taken care of here.

It also includes the situation you have in the case of first nations, which is true for veterans as well: over-the-counter drugs are given by prescription, so you have the doctor's time, the fee for the doctor to write a prescription for aspirin, and then you have the dispensing fees. This is a program design issue and there are a lot of elements in this. Obviously a point-of-sale computer system will not deal with that at all, so there are other parts of this system, that's quite correct.... We think this point-of-sale system will do one part of it, but it won't address the whole thing.

The Chair: For everybody's benefit, we will be hearing from the Department of Health on the Auditor General's report at our next meetings.

Ms. Caplan, you may have a very short question, with a very short answer.

Ms. Elinor Caplan: I just wanted to go on record as saying that I support the transfer-when-ready policy, because I believe that local governance gives you better results in program delivery. I'm concerned about the duplication and am wondering what role the local communities have had in the design of the programs, and whether or not it's something you've audited.

Ms. Maria Barrados: Madam Chair, duplication is not that much of an issue in the case of transfer because the set of programs is transferred and the community can redesign the programs to suit themselves. Duplication is an issue for the contribution agreements when they're separate agreements. This is a stepping stone to transfer, and it's that portion of it where it's particularly problematic.

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The Chair: Mr. Hill.

Mr. Grant Hill (Macleod, Ref.): Thanks very much.

It doesn't inspire a lot of confidence to have sat here in the last Auditor General's report and heard many of these comments and promises that things would improve, and sit here a few years later and find, if anything, they are worse. So I think it's something for us to consider that we've heard this before.

I'd like to know who the new contractor is that is taking the place of Liberty and Blue Cross, for the rest of the committee's information.

Ms. Maria Barrados: It's a joint venture between the Tribal Councils Investments Group of Manitoba Limited, a prominent Manitoba investment company with a record of successful investments, and Aetna Health Management Canada Inc., a leading group benefits provider. I'm reading this from the press release from Health Canada and Public Works.

Mr. Grant Hill: Would you have the opportunity to review the new contract prior to having these same problems recur?

Ms. Maria Barrados: Would we have the opportunity? I'm hesitating because we have a lot of opportunity to do a lot of things. The question is whether we would want to and whether it would be appropriate.

We have had the commitments made to us that the kinds of concerns we raised would be taken care of. We will follow up.

Mr. Grant Hill: It's not too reassuring to me, because I heard the very same commitments made in 1993. I presume that means you could do it but haven't been given the opportunity.

Ms. Maria Barrados: It means we could do it. I'm not sure whether it's a value-added thing for us to do.

Mr. Grant Hill: I suggest it would be value-added, because four years hence I would hate to hear the same story again.

Finally, I find the issue of over-the-counter products needing prescriptions mind-boggling. Aspirin for any other Canadian citizen does not require a prescription. It certainly doesn't engender an $8 prescribing fee, nor does it engender the time to visit a physician. As a physician in my own province, I know this does not exist in Alberta. It's not necessary to have a prescription in Alberta for an over-the-counter product. I took the time to check with pharmacists in communities other than my own. Is this changing?

Ms. Maria Barrados: This route is required if a first nations person doesn't pay for it himself or herself. As a first nations individual, you have to have a prescription and you have to give it to a pharmacist to dispense if you expect the benefit to be paid. If you pay for it out of your own pocket, it's not a problem.

Mr. Grant Hill: That's not the case in Alberta, where over-the-counter preparations are available through a pre-approval process.

Ms. Maria Barrados: Is that for first nations people?

Mr. Grant Hill: Yes. I presume, since Alberta is one of the largest provinces with the largest native population, this has been dealt with.

Ms. Maria Barrados: When we were doing the audit work that wasn't the case, but perhaps things have changed.

Mr. Grant Hill: I've been in practice for 25 years and I've dealt with thousands of these issues. It's never been the case in my own practice in Alberta.

The Chair: Would it help, Mr. Hill, if we asked the department about that when its representatives come?

Mr. Grant Hill: Believe me, it will help.

The Chair: Okay.

Mr. Maurice Vellacott (Wanuskewin, Ref.): Is there any possibility of integration of the provincial plans on this matter? Is there presently any way to work together before transfers take place, or has that been explored at all? Is that ever done so you don't have the overlap and the point-of-sale problems and so on?

Ms. Maria Barrados: In all these health programs there are provincial programs and activities and there are enormous variations, as you well know, by province. There are closer working relationships with some provinces than with others, but first nations very much view that this is a federal responsibility.

Mr. Maurice Vellacott: Okay. Thank you.

The Chair: Mr. Drouin.

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[Translation]

Mr. Claude Drouin (Beauce, Lib.): Ms. Barrados and Mr. Campbell, you talk about a threshold which, if exceeded, could cause some alarm since we are dealing with a major problem here. Do you think that we could have a penalty mechanism for those distributing and prescribing such drugs? If these drugs are prescribed, I suppose it is in someone's interest. If we set up a penalty mechanism, I think that we could control the problem, at least in part. Is it feasible? I'd be interested in knowing your opinion on this.

[English]

Ms. Maria Barrados: There are recourses the department can take in the case of improper payments. It could go for either recovery or criminal procedures. There are also recourses in terms of penalties that go through the professional institutes.

[Translation]

Mr. Claude Drouin: Thank you.

[English]

The Chair: You're finished? Thank you.

Mr. de Savoye.

[Translation]

Mr. Pierre de Savoye: When there's overconsumption of drugs, it's because somewhere a professional has prescribed them and another professional has filled the prescription. You don't need the latest computerized system to track it down. Aboriginals do not have access to thousands of different professionals, at least not individually. Previously my colleague Mr. Hill mentioned that this was not the first time we've heard about this problem in the committee. It would appear that appropriate measures have not been put in place.

We are dealing with a system that was designed to be expensive and to the advantage of anyone except Aboriginals. I'm glad our Auditor General has produced a full report on this. What I'd like to know from you, Ms. Barrados, is what kind of questions we can ask from the Department of Health when representatives appear here. What kind of questions can we ask to produce results? After all, the Standing Committee on Health, as you may remember, tabled a report last year on this subject after holding hearings with a large number of Aboriginals. What can we do to achieve some kind of result? Do you have any good ideas for us?

[English]

Ms. Maria Barrados: Madam Chair, I'll try.

One of the difficulties that we see here is the phenomenon of doctor shopping and pharmacy shopping. That means many visits to many doctors and many pharmacists. An important element for dealing with this is the kind of point-of-sale computer system that the department is talking about putting in place.

With respect to the question of what your committee could ask, I would strongly recommend that the committee pursue what kind of progress is being made in putting this point-of-sale system in place. How fast is it being done? What are the results of the pilots, those first efforts that are put in place? What are the results with respect to the results obtained on the warning messages? What is being done in terms of getting the information required to feed into those warning messages?

As we identified in the audit, there was a lot of difficulty with the code on doctors. You really couldn't quantify how much doctor shopping was being done. There could be questions posed on whether or not the department is putting in place thresholds of acceptable levels, because there aren't many thresholds that the department itself has put in place. We use the thresholds from other systems to set examples of what we thought looked like inappropriate levels.

These are the kinds of questions that certainly could be pursued with the department in terms of progress being made on this system. And further, I think it would be quite appropriate for the committee to ask questions about the specificity of that contract and the kinds of audit provisions that are being put in that contract. How are the problems we have identified being dealt with now, during the transition of contractors? That's the other thing that is occurring. So there are a number of areas.

• 1200

[Translation]

Mr. Pierre de Savoye: Thank you, Ms. Barrados. Thank you, Madam Chair.

[English]

The Chair: Mr. Myers.

Mr. Lynn Myers: I want to ask a specific question about page 13-25, exhibit 13.15. I wondered if there was an easy and quick explanation for the province of Alberta being so high relative to the others.

Ms. Maria Barrados: Madam Chair, I'm not sure I have an easy or quick explanation for why that province is higher than the others.

Mr. Lynn Myers: Would Health Canada have it?

Ms. Maria Barrados: It's a good question for Health Canada.

My colleague reminds me that I should point out that it's not adjusted for population. If you started to adjust for population, you would see some shifting in some of these numbers, but not in the western provinces.

Mr. Lynn Myers: Thank you.

Ms. Judy Wasylycia-Leis: I would like to come back to the question of systemic problems behind the issues that we're seeing come to the surface in first nations communities and that are documented in your report.

You've indicated that there is a sense that a reasonable process is in place for ensuring transfer agreements that take into account the health care needs of the first nations and Inuit people, that take into account the right of every member of those communities to have access to quality, medically necessary services. You've indicated that there is some process in place with respect to developing the capacity in first nations and Inuit communities to provide the health care services once transfer arrangements are in place.

My sense is that there is still a long way to go in terms of discussions between the aboriginal communities and the Department of Health to make this a reality. In fact, it seems there's a great deal of pressure to move quickly without having those issues addressed. There's certainly a strong sense, at least in the current discussions, that funding will never address the growing needs in the communities. Given the fact that they're operating under about a 1% increase in funding this year while the population is growing at 3%, we're going to keep seeing enormous problems in terms of the kinds of health care issues that you have identified in your report.

Can you elaborate a bit on what you see as being in place? What should we be recommending to the federal Minister of Health in terms of how to improve that process so that there is a sense that all of these issues are on the table now, and that time permits full and complete dialogue around those basic issues?

Ms. Maria Barrados: Madam Chair, if I might offer some comments, I think it's true that there are mixed messages to people in Health Canada, the bureaucrats delivering the programs. I think there could be a valuable contribution in clarifying what that message is. What I mean here is that there is a message about pushing very hard to transfer—and to move to transfer is a policy—but at the same time, there are ongoing obligations that are still there.

We highlighted in the report that there had not been enough attention paid to those management responsibilities that are still in place. That is an extremely important part of what the people in Medical Services Branch should be doing, because it is the delivery of these services and programs for the benefit of first nations people, but it is also building the capacity so that transfer can take place.

I think this is an important item that has to be clarified for the people who are actually delivering the programs. There is some formality that is required, along with a systematic approach to these contribution agreements. There has to be work with the first nations on clarifying what is expected. There has to be work done to formally monitor what is occurring. You can't expect first nations to be preparing reports that nobody reads. You can't expect first nations to be giving a report that makes no difference, that is just a piece of paper that has to be filled in.

• 1205

Similarly, the message from Medical Services Branch is that these really are programs that need to be managed, and it matters that the effort is put into doing this work. It has an element of administration to it, and it has an element of form, but these are the kinds of skills that first nations people need when they take over the program.

In the case of transfer, responsibilities aren't entirely over. First nations people who have transferred are in a position to run these programs themselves, are in a position to take full responsibility for these programs, but there is still an accounting back for what has taken place, and an evaluation of what has taken place.

The reason for doing the transfer is a policy decision that says this is a better way to provide these programs to first nations people, that it is the best way to improve health status. What we recommend, then, is that it is important that after the transfer agreements have been in place, there is an effort to evaluate that this has really occurred. The reason we want to do so is that it is health status that is the most important thing. So if there are elements of the transfer that haven't worked, or if there are things that need to be changed, adjustments can be made as more programs are transferred and as other transfer agreements are renewed.

I guess the final point that was made concerned the growth in population and the increasing pressures on these programs. There's no question that this is occurring. In addition, there is this situation where the standard of health of first nations people is not up to the standard of health of the general population. There are two kinds of pressures that are here.

We believe, particularly in the non-insured health part, that there are a number of economies and efficiencies that can be made. These can be made with a view of reallocating that money to parts of need in the program. We've identified a number of these, and we've discussed some of those already this morning.

The Chair: Mr. Thompson.

Mr. Greg Thompson: Thank you, Madam Chair, but my question was actually answered by our witness, so I'll pass on questioning.

The Chair: Mr. Vellacott, Mr. Hill, you can share the time if you want to.

Mr. Maurice Vellacott: I have three questions, but I don't think I need long answers to any one of them.

In respect to arrangements with the various bands throughout the country, is there uniformity in terms of delivery of health services and a share of the dollars to respective bands? As you know, there are a variety of agreements in place across the country. Is there some uniformity, or do terms vary around the country presently before transfers occur?

That would be my first question. If I could get an answer to that, I'll then follow up with my second one.

Ms. Maria Barrados: Madam Chair, as I commented earlier, there are different provincial systems in place, different provincial programs, and different other kinds of programs. The agreements vary by province, depending upon what is in place in that province.

Mr. Maurice Vellacott: Are there mechanisms, are there ways to assure that the dollars are getting through to the women and children, the people of the band, then? Are there some kinds of things in place to assure that this happens—guaranteeing it, if you will?

Ms. Maria Barrados: My comments about the contribution agreements are exactly that. The contribution agreements are the formal arrangements in place between Health Canada and first nations, and should lay that out: for this amount of money, we expect the following to be done with the following result. For the transfer agreements, it is at a higher level: this package of money for you to run these things, with these kinds of results. Those mechanisms are the mechanisms that should be addressing that.

Mr. Maurice Vellacott: Right, so if that's not happening, some of these mechanisms will trip and this will come into play. They can flag it and say this is not occurring, and the department can begin to get involved in some greater way at that point.

Ms. Maria Barrados: Madam Chair, our comments about the undermanagement or the not-sufficient management attention on the contribution agreements are precisely the concern that the mechanism wouldn't trip, because nobody is really looking at the mechanism.

• 1210

Mr. Maurice Vellacott: This is my last quick question, then, and it's about the whole issue of accountability by the band leaders and so on back to the department. Is there any accountability or means whereby there's an accountability to the grassroots, to the aboriginal people themselves on the respective reserves?

Ms. Maria Barrados: It's a very important element of transfer that the accountability work both ways, so that the accountability goes back to Health Canada and the accountability goes to the band members.

I'll just take a minute to comment on another piece of work we did on accountability with first nations people. Our starting position was this question: Are first nations people prepared to be accountable? The result of that work was yes, first nations people are prepared to be accountable, but it has to have a purpose and a point, and the accountabilities have to work both for the first nations people to their people and to Health Canada. In those instances, they were quite prepared to be accountable.

Mr. Maurice Vellacott: I just want to clarify this. I was talking about the leaders being accountable to their own people with respect to the delivery of health care.

Ms. Maria Barrados: In the case of the transfer agreements, that is what is expected. In the case of the contribution agreements, it has been set up entirely between the first nations and Health Canada.

Mr. Maurice Vellacott: Okay.

The Chair: We have time for a very short question from Mr. de Savoye.

[Translation]

Mr. Pierre de Savoye: Ms. Barrados, I gather that non-insured health benefits are not part of the department's mandate or responsibility. You mention the department has taken upon itself to have a policy of this nature. Is the Auditor General recommending that the House of Commons clarify the mandate of the Department of Health with respect to the provision of these non-insured health benefits?

[English]

Ms. Maria Barrados: Madam Chair, the last time we did this audit we pointed out this lack of legislative base for the non-insured health benefits and the importance of clarifying what the objective was for this program. The department has done this through policy and has clarified the objectives for the program. It still does not have a legislative base.

One of the reasons these things occur is that in the case of first nations, as you all well know, it is very difficult to legislate in these areas because there are a very complex set of questions involved.

[Translation]

Mr. Pierre de Savoye: You didn't answer my question. I asked you whether you were of the view that the House of Commons could legislate on this matter or decide to allow the present situation to continue. What is your opinion?

[English]

Ms. Maria Barrados: It is the view of our office that it is appropriate and desirable to have a legislative base for all the programs that are delivered.

[Translation]

Mr. Pierre de Savoye: Thank you, Ms. Barrados.

[English]

The Chair: As the chair, I'm going to take the prerogative of asking the last questions.

Based on this audit of the programs, could you provide us with an example or examples of first nations and Inuit communities where the transfer agreements have produced measurable benefits?

Ms. Maria Barrados: Madam Chair, I'm not sure I can give you the specificity you're asking for. One example the auditors looked at met all the requirements. Perhaps I could provide the specifics of that example to you afterwards.

The Chair: All right. You can provide it to the clerk of the committee.

I would like to thank you and all the other people from the department who are here today.

Members, we won't take a break. We'll just continue on as they're moving out.

We didn't have coffee today, as you've noticed. It saved us $60, but I'm not sure if that's a concern. We'll have it next time. If nobody minds, maybe we don't need it.

Ms. Aileen Carroll (Barrie—Simcoe—Bradford, Lib.): We don't need it at 11 a.m.

The Chair: You don't need it at 11?

Are there any other feelings about this?

Ms. Aileen Carroll: If we're meeting early we do need it.

Mr. Joseph Volpe (Eglinton—Lawrence, Lib.): Put the money to our travel budget.

Some hon. members: Oh, oh.

The Chair: Maybe we should just have juice and water for the health committee.

Mr. Thompson, just juice and water?

Mr. Greg Thompson: Juice and water is fine.

The Chair: Without coffee, we'll save the $60 at other times too. We'll set a good example. We'd better send a press release out.

Some hon. members: Oh, oh.

The Chair: Before we get to our motion, I'd just like to comment on the fact that I don't have a stopwatch here. I may have to get one. If I do cut somebody off, I'll give them an extra minute or whatever another time. I'm trying to be fair. If I do go over or under, I'll try to make an adjustment. You can put up your hand or cry or whatever it takes to get my attention.

• 1215

We have a motion before us. Does everybody have a copy? The motion is a little bit redundant. It is part of the government platform, and we do have it in the throne speech, but it is a motion. We'll allow Mr. Thompson to make a comment on his motion. If anybody else would like to make a comment afterwards, we'll let each person comment on it, and then Mr. Thompson can make the final remark if he has anything to add.

Mr. Greg Thompson: It's pretty straightforward. Actually I don't have my motion.

The Chair: Mr. Thompson, just a moment, please.

Madame Picard, is there something about the motion?

[Translation]

Ms. Pauline Picard (Drummond, BQ): Yes, I was raising my hand to speak after Mr. Thompson. You asked...

[English]

The Chair: Okay.

Mr. Thompson, do you want to make a 30-second comment, or is it all right just to accept it as it is?

Mr. Greg Thompson: No, I'm sure all members have read it, and I think it's pretty straightforward, Madam Chairman.

The Chair: Thank you.

[Translation]

Ms. Picard.

Ms. Pauline Picard: I'm opposed to the motion. I believe the federal government should consider that health care is basically a provincial responsibility. You know that in Quebec we did not wait for the federal government to set up this kind of program. If the committee were to adopt the motion, we would make a point of expressing our disagreement in the report.

[English]

The Chair: Are there any other comments? Mr. Volpe.

Mr. Joseph Volpe: We would take the same position on this motion, but for different reasons.

Madam Chair, as you've already indicated, the government already has announced a program whereby approximately $150 million will be spent over the course of the next three years to look at the viability of such a program. For us to engage ourselves immediately in discussing the advantages and disadvantages would probably be pretentious at the very least, premature as well, and probably very ineffective and inefficient.

Without being personal about this, Greg, I hope you'll withdraw it so we don't have to shoot it down.

Mr. Greg Thompson: Well, I guess I'm forced to respond now.

Mr. Joseph Volpe: Just say you'll withdraw it; that's all.

The Chair: Mr. Thompson, if could you just hold it for a second, we have somebody before you.

Yes, Madam.

Ms. Judy Wasylycia-Leis: Thank you, Madam Chair.

I don't have a problem supporting the motion. It's an important issue that is worthy of the committee's attention, especially given the fact that this was a very clear commitment made during the election and now has become of much lesser significance in the current parliamentary agenda, based on what the minister has said. There are real concerns about moving as quickly as possible to some sense of what a national drug plan could be for this country.

My only concern is this. I raise the same question I did at the last meeting, and that is, at what point will we look at a number of pressing issues and plan our agenda to schedule those concerns, those themes, taking into account all of our needs? I could draft a lot of motions for the next meeting based on other issues that I think are important, but I don't know if that's the appropriate way to go. Maybe in fact we do need a steering committee meeting to look at that.

But certainly, on its own, I will support the motion.

The Chair: Maybe you could ask the minister that when we have the minister here at the meeting.

Is there anybody else who would like to make a comment? Mr. de Savoye.

Mr. Pierre de Savoye: Such a plan has been operating in Quebec for over a year now. I understand for the rest of Canada it could be beneficial too, so I understand why this issue is important to my friends here and certainly to every one of us. But think of it for a second. Why should Quebeckers, with their tax money, pay for a duplicate thing? We already have that. So if we ever are going to vote on this thing, one of the disadvantages I would point out quickly is that Quebeckers are paying twice for the same thing and should be exempted.

Mr. Joseph Volpe: You're already prejudging what might be in the study.

• 1220

Mr. Pierre de Savoye: My point, Madam Chair, is I understand the need of such a program for the rest of Canada, but this is a clear example of how we are duplicating things, Quebec already having its own plan and funding it.

The Chair: Mr. Thompson, you get the last word.

Mr. Greg Thompson: Thank you, Madam Chair. You're really generous this morning. I appreciate it.

In response to the previous member, obviously that's the purpose of a national pharmacare program, so there will not be duplication, Madam Chair. That's exactly why I suggested we study this issue now, because I agree with him: it's not Quebec versus the rest of Canada in the sense of duplication and a double tax whammy, it' simply taking the time to examine a national pharmacare program. And as Madam Chair indicated, it is part of the government's throne speech.

I would like to believe this is one time, among many, Madam Chair, when I'm working in complete cooperation with the government and hoping we can move to this issue very quickly, because it was obviously in your red book two as well, and I think it's time we used the resources of the committee to do a full investigation of the issue. I really don't believe it would be a waste of taxpayers' money, because obviously that's why we are here. That is why we are being paid as members of Parliament. And it would be the most efficient use of a resource right here on Parliament Hill, starting now.

Thanks, Madam Chair.

The Chair: Thank you, Mr. Thompson. Thank you for your cooperation. I am sure the government appreciates that.

I'll now put the question.

(Motion negatived) [See Minutes of Proceedings]

Mr. Reed Elley: Just keep us out here, Madam Chair.

The Chair: Just the first question, second question.

Mr. Greg Thompson: On a point of order, Madam Chair.

The Chair: Yes.

Mr. Greg Thompson: I would prefer, Madam Chair, that we would have a recorded vote on this particular issue.

The Chair: Another time, we'll ask for that a little earlier.

Ms. Judy Wasylycia-Leis: I wanted to raise very briefly the concern I raised earlier and in the context of your response, Madam Chair, around the setting of the agenda for this committee.

On a number of occasions you have suggested we should ask the minister this question. I know we will be hearing at some point from the minister about his priorities, but I also believe that the role of the standing committee is to look at setting its own agenda and that it has some measure of independence. In fact we need to pursue this issue in terms of all parties being represented around the table and the kinds of issues we want to see discussed here.

The Chair: We could do that. Possibly, if I could just comment on that, we may be able to schedule a future business meeting the week of November 17, in that period.

Yes, sir.

Mr. Reed Elley: Madam Chair, we did have two motions that we introduced last meeting, which you said would be dealt with at this meeting. Is that your intention?

The Chair: We dealt with them at the last meeting, I believe.

Mr. Reed Elley: No, you didn't.

The Chair: I said that they were.... What's that word?

A voice: Ruled out of order.

The Chair: I think they would have to be—

Mr. Reed Elley: You had them last week. Is that not 48 hours for this week? We can keep putting this off.

The Chair: No, I'm not trying to put it off.

Madam Clerk, do they have to be resubmitted when they were...?

The Clerk of the Committee: No. I thought they had been dealt with at the last meeting.

Mr. Reed Elley: No, they were not dealt with. They were ruled as substantive orders that needed motions that needed 48 hours, and I presumed giving the motions at that point would be 48 hours.

The Chair: I understood we ruled them out of order, and once you've ruled them out of order they would have to be represented in order to be brought up again. Is that correct? Is there consensus that's what we did?

Mr. Joseph Volpe: That's exactly what happened.

Mr. Reed Elley: Madam Chair, there is one more thing then. We in the Reform Party would like to have this minuted and to go on record that we were against the in camera meeting that was held last week, because it was not according to Beauchesne's. Beauchesne's says “the final decision for whether to sit in camera rests with the members themselves”. We hope that won't happen again.

The Chair: All right. Thank you.

Any other comments? Yes, Madam Bennett.

• 1225

Ms. Carolyn Bennett (St. Paul's, Lib.): I wanted to comment—like Judy, Madam Chair—that I think it's really important that this committee does set an agenda of priorities. I would suggest that after the minister has given us his shopping list we present our own shopping list and that we as a committee sort out what order we are going to do things in so that we don't have motions like this that we have to defeat because we don't have an overall blue-sky plan.

The Chair: Fine.

We are adjourned until November 18.