|
The Committee sought to examine firsthand the
unique HHR needs, challenges and innovations in Canada’s northern territories
through a fact-finding mission to Iqaluit and Rankin Inlet in Nunavut from May
24 to 26, 2009. During the course of its visit, the Committee met with the
Government of Nunavut’s Health and Social Services (HSS) Department officials,
as well as local health professionals during its site visits of local hospitals
and community health centers. This chapter highlights the unique HHR challenges
related to health care delivery in the North, as well as local solutions
developed to meet the health and cultural needs of northern populations.
During its visit to Nunavut, the Committee
learned that health care delivery in the North was substantially different than
in the rest of Canada. According to Department officials, Nunavut has one full
service hospital with surgical facilities, Qikiqtani General Hospital located
in Iqaluit and two regional health centers with expanded services and full time
family physician coverage located in both Rankin Inlet and Cambridge Bay. Other
communities have community health centers that are staffed by nurses who have
24/7 access to physician back-up in Iqaluit. The Committee also heard that
two continuing care facilities with 20 beds will also be opening in Nunavut.
The Committee learned that primary care is
very different for family physicians and nurses in Nunavut than it is for other
regions in Canada. The Committee heard that there are 24 full-time equivalent
family physicians or general practitioners in Nunavut, with 14 located in
Iqaluit and the others travelling to communities across the territory.
Department officials indicated that many of these physicians were working in
Nunavut temporarily on locums. Meanwhile, the Committee heard that specialists
also come to Nunavut on a short term rotational basis. As a result, primary
care in Nunavut is primarily delivered by nurses, while family physicians
frequently act as consultants to the nurses. Physicians only take over primary
care in difficult cases and provide other services, including obstetrics,
anaesthesia and managing patient care.
As a secondary or tertiary care is only
available in certain communities in Nunavut, the Committee heard that many
people must leave their home communities to receive these services.
Consequently, the HSS Department has established three main North-South
transportation routes for patients needing secondary or tertiary care outside
of Nunavut’s three main regions: Qikiqtani Baffin Region (East), Kivalliq
Region (Centre) and Kitikmeot Region (West). The Committee heard that Kitikmeot
Region sends patients to Yellowknife or Edmonton; patients from the central
region travel to Winnipeg; and patients from the Baffin region travel either to
Iqaluit or Ottawa for treatment. As a result, medical travel constitutes a
significant portion of the HSS Department’s budget: approximately $50 million
annually or about 18.5% of the total budget. However, department officials
indicated that they expected travel costs to decline with the increased use of
telehealth.
The Committee heard that Nunavut faced unique
challenges in the recruitment and retention of health professionals. During
their site visit of the Qikiqtani General Hospital, the Committee learned that
the hospital had difficulties recruiting and retaining staff because there was
a lack of housing in Iqaluit. The hospital administrator pointed out that with
the short building season of approximately four months and the high demand for
housing in Iqaluit, very few housing units are available to offer to potential
nurses and physicians. The Committee also heard that despite an aggressive
recruitment strategy, Nunavut was unable to offer sufficient bonuses and
incentives to recruit health professionals to the region. In particular, the
hospital administrator indicated that Nunavut was unable to offer sufficient vacation
travel allowances, which enable physicians and nurses to travel outside of
Nunavut for vacation and continuing education. The Committee also heard that
the Qikiqtani General Hospital is currently facing staffing shortages of 40%,
while only 54% of nursing positions in Nunavut remain filled.
With respect to the recruitment of
physicians, HHS Department officials indicated that licensure requirements were
a barrier to practice for physicians from other regions in Canada. However,
they noted that the Agreement on Internal Trade was a positive step in
harmonizing licensing requirements for physicians across the country. Furthermore,
they saw the Mutual Recognition Agreement signed by Ontario and Quebec, allowing
for the mutual recognition of physician credentials in both provinces, as a
possible solution for Nunavut.
In terms of the recruitment and retention of
local populations into the health workforce in Nunavut, the Committee heard
that many Inuit students face barriers in pursuing health careers at Nunavut
Arctic College. Administrators of Nunavut Arctic College pointed out that very
few Inuit students are able to attain their high school diploma, a
pre-requisite for entering the nursing program. Moreover, many students face
the challenge of studying nursing in their second language of English, rather
than their native tongue. Many students at the College are also mature students
with competing family obligations. The Committee heard that though the Arctic
College was successful in training many nurses despite these barriers,
approximately 30% did not remain in Nunavut, but rather sought positions in
other parts of Canada.
Administrators at the Qikiqtani General
Hospital indicated that the employment of local staff also presented its unique
challenges. They articulated that many Inuit staff were reluctant to take on
management roles in the hospital because it would venture beyond the scope of
practice in which they were trained. Furthermore, they indicated that many were
uncomfortable in taking on a role that could require them to reprimand other
staff for poor work performance, who could also be fellow community, and
possibly family, members.
Finally, Department officials spoke against
the recruitment of IEHPs as a possible solution to HHR shortages in the North.
The officials indicated that though they had signed a contract for 100 nurses
from the Philippines, very few of them passed the exam enabling them to
practice in Canada. Moreover, the cultural challenges IEHPs face are
significant as they would have to adapt to health care delivery in the North to
a very specific population group. Further, the scope of practice required in
Nunavut far exceeds the training and capacity of many foreign-trained nurses.
Departmental officials emphasized however that those nurses who had overcome
these challenges were some of the best nurses in the territory. Department
officials therefore recommended that IEHPs should undergo at least one year of
training or practice in southern Canada before entering practice in Nunavut.
In order to address some of these challenges,
Department officials recommended that federal funding though the Territorial
Health System Sustainability Initiative and the Medical Travel Fund be
sustained. They further recommended that federal funding to Nunavut take into
account the differences between the challenges faced by the Inuit living in the
North and First Nations population groups living in the South.
Through its various site visits, the
Committee learned of various programs and initiatives that have been developed
to meet the local population health and cultural needs. The Committee learned
about Nunavut Arctic College’s mental health councillor program aimed at
training students to address the mental health needs of the local population,
including addictions, suicide and legacies from residential schools. Students
in the program were also mentored by traditional healers to help better
integrate them into the community. In addition, Nunavut Arctic College had also
developed laddering programs where students learned how to transfer and build
upon the health related skills that they had developed in one health profession
and apply them to a more advanced health related career. For example, students
trained as home care workers were able to build upon their existing training as
a launching pad for entering into nursing. The Committee also visited the
Rankin Inlet Birthing Program located at the Kivalliq Wellness Centre, which provides
family-centered care to pregnant women in the community. The Birthing Program
is an initiative of local Inuit women, who wanted to enable women to give birth
in their communities with traditional birthing practices. At the Wellness
Centre, midwives provide comprehensive pre- and post-natal care along with
counselling to women with low risk pregnancies. Delivery is then performed at
the Kivalliq Health Centre with the help of the midwives. Staffed by two permanent registered midwives, one
casual registered midwife, and one maternity care worker, the Committee was
pleased to learn that the program strives to incorporate traditional customs
into the birthing practices, including involving fathers and traditional
non-registered midwives.
Through its fact-finding mission, the
Committee gained insight into the particular HHR challenges facing Canada’s
northern populations in the areas of recruitment and retention and health care
delivery. The Committee also learned that many of the health challenges in the
North, including rising rates of diabetes, obesity, sexually transmitted
infections (STIs) were linked to the broad determinants of health, such as
poverty, access to healthy food, and loss of identity and culture related
issues. These comments suggest that a broad approach towards addressing HHR challenges
in the North is necessary, including focusing on health professionals that use
preventative approaches and promote mental health and overall wellness, as well
as addressing other determinants of health such as poverty. The Committee
learned that the health challenges faced by northern populations also needed to
be understood as distinct from those of First Nations living in south, as well
as other Canadians. This is due in part to geography, which limits access to
low cost healthy foods that can lead to poor health outcomes such as diabetes,
dental problems and obesity, as well as hinders access to care and treatment
for populations living in remote communities. The Committee therefore
recommends:
Recommendation 26:
That Health Canada, Indian and Northern Affairs Canada, and the
Public Health Agency of Canada utilize health professionals and program
officers with expertise in food security and recreation as part of their
programming in Nunavut..
Recommendation 27:
That the Government of Canada consider sustaining its funding of
the Territorial Health System Sustainability Initiative and the Medical Travel
Fund beyond 2012.
Recommendation 28:
That the Government of Canada continue to take into account the
differences between the challenges faced by the Inuit living in the North and
First nations populations living in the South in its funding decisions.
Recommendation 29:
Over the course of its fact-finding mission in Nunavut, the Committee
heard of the difficulties faced by Inuit living in Nunavut in gaining access to
spots in provincial faculties of medicine, the Committee therefore would like
to bring this to attention of the Association of Faculties of Medicine Canada
and requests their feedback on this issue.
|