Introduction

A. Background

On 26 May 2021, reports from the Office of the Auditor General of Canada (OAG) were tabled in the House of Commons and referred to its public accounts committee (the Committee) for study.[1] Among these was an audit report entitled “Health Resources for Indigenous Communities.” This report summarizes the OAG’s report and sets out the Committee’s recommendations to the audited organization, Indigenous Services Canada (ISC or the department).

B. Key definitions

The following definitions apply to the entire report.

Table 1 - Definitions

Source: Office of the Auditor General Canada, Health Resources for Indigenous Communities—Indigenous Services Canada, Report 11 of the 2021 Reports of the Auditor General of Canada.

C. Audit parameters

The key parameters of the OAG performance audit are summarized in Table 2.

Table 2 – Audit Parameters

Source: Office of the Auditor General Canada, Health Resources for Indigenous Communities—Indigenous Services Canada, Report 11 of the 2021 Reports of the Auditor General of Canada.

D. Roles and responsibilities

The roles and responsibilities of key stakeholders in providing health resources to Indigenous communities are listed in Table 3.

Table 3 – Roles and Responsibilities

Source: Office of the Auditor General Canada, Health Resources for Indigenous Communities—Indigenous Services Canada, Report 11 of the 2021 Reports of the Auditor General of Canada.

E.Meeting of the Public Accounts committee

On 3 March 2022, the Committee held a meeting on the OAG report with the following in attendance:

• OAG – Andrew Hayes, Deputy Auditor General; Glenn Wheeler, Principal; and Doreen Deveen, Director
• ISC – Christiane Fox, Deputy Minister; Dr Tom Wang, Chief Medical Officer, Chief Science Officer and Director General; and Robin Buckland, Director General and Chief Nursing Officer[2]

Findings and recommendations

A. Personal protective equipment

1. Insufficient amounts of some PPE items before the COVID‑19 pandemic

The OAG noted that ISC did not procure PPE according to its 2014 procurement approach. This approach “outlined how much stock it needed to purchase over a 4-year period to be ready for a moderate to severe communicable disease emergency.”[3] As a result, “in March 2020, the department did not have the stock it committed to in its approach for some items.”[4] ISC Deputy Minister Christiane Fox explained the 2014 strategy:

We were able to recognize that, although the 2014 strategy was a hybrid one, we were exclusively counting on equipment from the Public Health Agency of Canada. Moreover, as we have seen since the beginning of the pandemic, there was a true shortage of equipment internationally.

If we look at the 2014 model and where we are now, the changes we have had to make have primarily consisted in not relying strictly on equipment percentage and what we received directly from the agency, but also in meeting needs by purchasing directly from the department. It is also important to say that measures may not have been in place in 2014 for a daily review to be carried out.[5]

The Public Health Agency of Canada (PHAC) was to allocate 80% of bulk purchases of PPE to the provinces and territories, 18% to the National Emergency Strategic Stockpile and 2% to ISC for its own stockpile during the pandemic.[6] PHAC told the OAG that “the cost of the 2% allocation to [ISC] resulting from Federal-Provincial-Territorial bulk procurement, from 1 January 2020 up to 31 March 2021, was approximately $20 million.”[7] The department was also “able to rely on the National Emergency Strategic Stockpile for additional PPE during the pandemic to respond to requests from Indigenous communities and organizations.”[8]

2. PPE provided when needed during the COVID‑19 pandemic

a) Expanded access to PPE

The department provided PPE to Indigenous communities and organizations when provinces and territories were unable to provide it.[9] At the beginning of the pandemic, ISC expanded access to the stockpile to include not only health care workers but also police officers, water monitors and people who were sick with COVID‑19 or taking care of a sick family member.[10] Christiane Fox explained:

We provided PPE to the 51 communities and their health care workers, but we did not limit our PPE stock to just those health workers. If a school called, if a police officer called, if there were needs in the community, we did everything we could to respond to that need, and that was not limited to on reserve. We actually sent PPE supply to urban indigenous centres to be able to provide those essential supports for urban indigenous individuals who found themselves out of the community or even in very dire situations, in terms of the indigenous homeless population.[11]

Figure 1 shows the amount of PPE provided by ISC during the pandemic, by province.

Figure 1 – Number of Items of PPE Provided by ISC, by Province

Source: Office of the Auditor General Canada, Health Resources for Indigenous Communities—Indigenous Services Canada, Report 11 of the 2021 Reports of the Auditor General of Canada, Exhibit 11.2.

The OAG noted that variations in the amount of PPE that ISC provided to the provinces “can be partly explained by rates of COVID‑19 cases in different parts of the country, and because other sources of [PPE] were unavailable.”[12] Christiane Fox stated that resources were provided based on the needs and the size of Indigenous communities.[13] For example, “Northern Manitoba and Ontario were probably our most challenged communities in terms of the outbreak.”[14]

b) Timely provision of PPE

The OAG found that ISC had provided PPE to Indigenous communities and organizations in a timely manner. From March 2020 to the end of November 2020, 82% of requests were processed within two business days or less. The average time from receipt of request to receipt of equipment was 10.5 calendar days, which includes 1.6 business days for ISC processing. The longest processing time was 12 business days.[15]

3. Collaboration between the department and its partners

The OAG found that the department “met with Indigenous communities and organizations throughout the pandemic to discuss how it could support them with the PPE that they needed.”[16] ISC told the OAG that it also “had ongoing communications with federal organizations and the provinces and territories.”[17]

4. Processing PPE requests

From March to August 2020, the department’s process for managing PPE involved multiple steps that relied on manual inputs of requests. According to the department, “this led to errors in capturing information on requests. The department did not always have complete and accurate information on the amount of PPE that was being sent to communities and organizations from the stockpile.”[18]

In September 2020, the department introduced a new system to electronically process PPE requests. According to the OAG, “this system reduced the possibility of human error and led to more complete and accurate information on requests for PPE.”[19]

5. Management of PPE stockpile

The OAG found that, during the pandemic, “the department did not have complete and accurate data on the contents of its PPE stockpile.”[20] Some shipments of PPE were, at times, accounted for in the inventory several weeks to over a month after the shipment was received. In other cases, there were discrepancies in the amount of items of PPE logged in the inventory.[21]

Christiane Fox emphasized the importance of improving the department’s data:

Data … is a huge area of concern in terms of well-managed health human resources and health services that are culturally relevant …

… for data from our nursing stations that support communities, we should have access to better systems. These go beyond just the nursing station in terms of how they interact with the provincial data systems.[22]

6. Recommendation

Given its findings regarding the department’s PPE stockpile, the OAG made the following recommendation:

Indigenous Services Canada should review the management of its personal protective equipment stockpile to ensure that it has accurate records and the right amount of stock to respond to the current pandemic and future public health emergencies faced by Indigenous communities and organizations.[23]

Christiane Fox stated that, in response to the recommendation, ISC “started working with the Public Health Agency of Canada on a joint automated inventory management tool.” The tool would “give [ISC] accessible, up-to-date information on the stockpile.[24] She also committed to testing the tool before the end of fiscal year 2021–2022:

The test we do involves everything. That test will be done before the end of the fiscal year, and we will begin soon. However, as you know, information technology systems must be tested. They also need strengthening. So we cannot just rely on the new system. We must work to ensure the system is good and reliable. As in any large project, there will be challenges. We must have strategies to address them. So that is the test we will start using at the end of the year.[25]

To maintain a stable PPE inventory and in anticipation of future needs, Christiane Fox said that “the department’s inventory target has increased from six to 12 months’ worth of equipment in its stockpile at all times.”[26]

Therefore, the Committee recommends:

Recommendation 1 – On personal protective equipment stockpile management

That, by 31 December 2022, Indigenous Services Canada present a report to the House of Commons Standing Committee on Public Accounts explaining the results of the department’s automated personal protective equipment (PPE) inventory management tool testing and stating whether the department’s target of having a 12-month supply of PPE was met.

B. Nurses and paramedics

1. Access to nurses and paramedics

Christiane Fox explained that “[i]n the pandemic, [ISC] saw an increased demand for surge support that would not necessarily have been common prior to the pandemic.”[27] For example, in 2019-2020, the department had received the equivalent of 86 days of intervention services in the 51 Indigenous communities. That number reached 15,371 in 2020-2021 and 22,232 in 2021-2022.[28]

During the pandemic, the department addressed extra needs for nurses by streamlining its staffing process through contracts with staffing agencies.[29] Christiane Fox described actions the department took during the pandemic to address staffing shortages:

During the COVID-19 pandemic health human resources was a challenge across the country. Therefore, we sometimes had to compete for that health human resource capacity. We had to think about what some of the creative ways were we could attract and retain. We worked with colleges and universities and with first nations-led institutions like [Saskatchewan Indian Institute of Technologies] to try to get that health human resource capacity in indigenous communities…

We relied on ISC nursing staff and contract staff, and then used different ways to advertise and look for skills. Even within our own group, we have nursing staff who are in communities. We also have nursing staff within the department who are doing policy work. We look at our own workforce. We look at the retired workforce. Could we bring people back to be on contract with us, even if part time?[30]

The department also “expanded access to its existing contract nurses by making nurses available to all Indigenous communities. It also created new contracts for nurses and paramedics to respond to COVID‑19 in any Indigenous community.”[31] Christiane Fox commented on the use of contract staff:

In terms of the contract nurses, is it a perfect system? It's not always. However, a lot of people don't necessarily want to commit to full-time employment, so this can be a really rich way to enhance the supports and have a workforce that we can call upon. We did have some successes in recruiting more people through the contract.[32]

To avoid interruptions to essential health services caused by the cancellation of flights to the 51 communities during the pandemic, the department chartered dedicated air services to transport almost 5,400 inbound and outbound passengers from April 2020 to March 2021.[33] Christiane Fox said this service cost approximately $51 million.[34] The department used a national master standing offer for two flight days at the very beginning of the pandemic, then a Public Services and Procurement Canada (PSPC) sole-source contract from March 2020 to June 2021, then a PSPC-tendered contract from June 2021 to March 2022.[35]

2. Inability to meet all requests for nurses and paramedics

The OAG found “that, despite expanding access to its existing contracts for nurses and creating new contracts for nurses and paramedics, the department was unable to meet over half of the requests for extra contract nurses and paramedics needed to respond to COVID‑19,”[36] from March 2020 to March 2021. 

As the pandemic progressed, both the number of requests for extra contract nurses and paramedics and the department’s capacity to provide contract nurses and paramedics increased. The OAG found that, despite increased capacity, the department was still unable to respond to all requests.[37]

Several factors contributed to shortages in Indigenous communities, including “the national shortage of nurses, the challenging nature of the work, the diverse skill set required to work in remote or isolated communities, and inadequate housing.”[38] Christiane Fox explained the housing problem:

The pandemic has exacerbated the housing shortage in some of our indigenous communities. We know this will affect not only community members, but also staff, such as nurses, professors and police officers who come from elsewhere and work in those communities. That is one of the challenges we are facing in recruitment.

Let’s take for example a community where, in normal times, we have enough housing for three to five nurses. However, owing to COVID‑19, more staff had to be sent there for augmented teams. Given that context, there was occasionally no housing available for everyone.[39]

3. Recommendation

To address the shortage of nurses and paramedics in Indigenous communities, the OAG made the following recommendation: 

Indigenous Services Canada should work with the 51 remote or isolated First Nations communities to consider other approaches to address the ongoing shortage of nurses in these communities and to review the nursing and paramedic support provided to all Indigenous communities to identify best practices.[40]

Some practices to attract and retain more nurses, such as allowances, are already in place. These include the educational allowance, isolated post allowance, recruitment and retention allowance, and allowances associated with nurse-in-charge and nurse practitioner positions.[41]

In its response to the recommendation, the department committed to “engaging First Nations communities in staffing processes.”[42] Christiane Fox said there is “indigenous leadership on the interview board.”[43] She also clarified what best practices the department would follow:

The first one, in terms of best practices, is probably the most important: ensuring that we have culturally relevant health services for indigenous communities. That means training. It means hiring indigenous professionals to manage health services. That is a best practice that needs to be across the country.

The second piece is around innovation. We talk about tools that can help us, like IT systems that can help track PPE, but beyond that, what are some of the innovations in terms of best practices that we can adopt? We have teams that now have connectivity. If you're in northern Saskatchewan, you can connect with a physician in Regina or Saskatoon. What types of virtual care technologies can we do?[44]

According to its action plan, the department intends to respond to the recommendation through three key action items: examine its current recruitment model (action item 2.1), enhance occupational health and safety capacity of the department to support ISC nurses (action item 2.2) and incorporate paramedics in the models of care and skill mix (action item 2.3).[45]

Regarding action item 2.1, the department intends to adopt a new strategy for nurse recruitment and update its branding products by March 2023. For action item 2.2, improving elements of the Nursing Services Response Centre is to be completed by March 2022 to improve the health and safety of staff. Lastly, under action item 2.3, contracts will be revised and policies updated to incorporate paramedics in the model of care by June 2023.[46]

To ensure that the planned actions are actually taken, the Committee recommends:

Recommendation 2 – On actions to address the shortage of nurses and paramedics

That Indigenous Services Canada present to the House of Commons Standing Committee on Public Accounts three reports outlining, with concrete examples: (1) by 31 August 2022, the changes made to improve the health and safety of the department’s nursing staff; (2) by 30 April 2023, its new nurse recruitment strategy and updated employer branding products; and (3) by 31 July 2023, the changes made to policies and contracts to incorporate paramedics into the model of care.

In addition, to determine the impact of planned actions on the shortage of nurses and paramedics in remote Indigenous communities, the Committee recommends:

Recommendation 3 – On the results of actions to address the shortage of nurses and paramedics

That Indigenous Services Canada present three reports to the House of Commons Standing Committee on Public Accounts that include A) indicators on shortages of nurses and paramedics in remote Indigenous communities, such as vacancy rates; B) number of requests for medical personnel and of requests met (including percentages); and C) indicators on housing availability, by 30 April 2023, 2024 and 2025.

Conclusion

The Committee finds that the Auditor General of Canada’s audit report concluded that weaknesses existed in Indigenous Services Canada’s management of its PPE stockpile prior to and during the pandemic. The department did not acquire PPE according to its 2014 procurement strategy. As a result, it lacked some PPE items at the start of the pandemic.

However, the department quickly provided PPE to Indigenous communities and organizations. The department also expanded access to its PPE stockpile to include Indigenous organizations, more Indigenous communities and additional individuals supporting the delivery of health services.

Finally, the department streamlined its processes for hiring nurses, expanded access to its contract nurses to all Indigenous communities, and created new contracts for nurses and paramedics. Despite this, the department was unable to meet more than half of the requests for extra contract nurses and paramedics needed to respond to COVID‑19.

In order to achieve the critical mission of protecting the health of First Nations peoples in remote or isolated communities, the Committee makes three recommendations to ensure that Indigenous Services Canada follows up on the Auditor General’s recommendations and provides evidence of such to the Committee through progress reports, for example on the shortage of nurses and paramedics.

Summary of recommended actions and deadlines

Table 3 – Summary of Recommended Actions and Deadlines