Terms of Reference (1996)
National Native Alcohol and Drug Abuse Program

General Review

1. Background:

The National Native Alcohol and Drug Abuse Program (NNADAP) is an example of a medical services branch (MSB) program now largely controlled by First Nations communities and organizations. Now in its fifteenth year, the NNADAP program includes a network of 54 treatment centres that represent approximately 700 inpatient treatment beds. As well, there are more than 500 alcohol and other drug abuse community based prevention programs with approximately 650 workers now active in community based prevention activities. 96% of the NNADAP resources are managed directly by First Nations through contribution and/or transfer agreements.

The goal of NNADAP is to support First Nations and Inuit people and their communities in establishing and operating programs aimed at arresting and off-setting high levels of alcohol, drug, and solvent abuse among their target populations living on-reserve. Most of the NNADAP activities are included in the following four areas of emphasis: prevention, treatment, training, research and development.

NNADAP has evolved through many stages, including identification of needs, program development and implementation, program maintenance etc. Alcohol and other drug abuse is a major health issue, and is a symptom of the continuing and complex issues related to the psycho-social health and wellness of First Nation individuals and communities. This is a priority for First Nation and Inuit people.

NNADAP has never been reviewed in its entirety, however, it was evaluated once in 1989. This evaluation included several recommendations aimed at making the program more effective and efficient, and to more closely meet the basic goals and intent of the program.

As MSB moves towards realizing the Branch Vision that "First Nations and Inuit people will have autonomy and control of their health programs and resources within a time frame to be determined in consultation with the First Nations and Inuit", it is now timely to re-examine NNADAP and determine what, if any, modifications should be considered in order to ensure that a viable and appropriate program is in place.

Through an informal process of discussion with a variety of players involved in a wide range of NNADAP activities, including prevention and treatment, a number of priorities were suggested for examination. Some of these issues include funding for NNADAP centres, demonstrated quality assurance of NNADAP services, current NNADAP reporting systems, as well as training and standards for prevention and treatment workers.

These and other issues identified subsequent to the discussion process will be examined in conjunction with the NNADAP Review exercise.

2. Pupose of the NNADAP Review:

2.1 To determine the overall effectiveness of the National Native Alcohol and Drug Abuse Program;

2.2 To guide the development of strategic recommendations to strengthen First Nations and Inuit programming in relation to alcohol and drug abuse by both MSB and First Nations communities

2.3 The Review is intended to support First Nations, Inuit and Medical Services Branch in their effort to ensure the most effective use of the NNADAP program at the community level.

3. Scope:

Review activities will be conducted in the context of the following general questions:

3.1 What was the original intent and contextual environment of NNADAP? What has the program accomplished? Is NNADAP achieving what it was originally established to do?

3.2 Who are the stakeholders and what are their roles and responsibilities in relationship to NNADAP? What are their perceptions of NNADAP?

3.3 What impact does NNADAP have on First Nations and Inuit people and communities?

3.4 What are the strengths and weaknesses of NNADAP? What are the opportunities and challenges for NNADAP? How can delivery of its programs be improved?

3.5 How does NNADAP relate to the provision of other programs at the community level? The study is to be broken down into the following components:

4. Literature Review:

A comprehensive literature review on substance abuse among First Nations and Inuit people. The literature review should:

4.1 be based on, but not limited to the continuum of care concept, including previous reviews (ie 1989, as well as project based studies), and existing evaluation practices;

4.2 contain some relevant international and non-native comparisons;

4.3 include information from the Treatment Activity Reporting System, also examine Non-Insured Health Benefits data in relation of cost, number and types of treatment referral to NNADAP/Non-NNADAP treatment centres;

4.4 Long Term Evaluation of Transfer-Final Report and MSB documents related to transfer policies;

4.5 Information gathered as part of this exercise should relate to, and be used where pertinent, to support any findings and recommendations developed in conjunction with the analysis of NNADAP programs and services.

5. Analysis of the NNADAP Projects and Services:

Identification, description, analysis of the NNADAP projects and services and recommendations with respect to:

5.1 Program governance;  

5.2 Program accountability;  

5.3 Roles and responsibilities of stakeholders;  

5.4 Availability, adequacy and accessibility of programs and services;  

5.5 Need for cross-addiction and multiple addiction substance abuse programs and services for First Nations and Inuit communities;

5.6 Impact of programs, services and care;  

5.7 Stakeholder satisfaction and perception of the NNADAP projects/services;  

5.8 Gaps in service delivery in relation to the continuum of care concept;  

5.9 Linkage to and impact of provincial programs and other agencies;  

5.10 Improvements to enhance overall effectiveness of programs and service delivery;  

5.11 Relationship of NNADAP with other community based services;  

5.12 Impact of transfer related policies and practices;  

5.13 Implications of devolution and transfer of programs and services for First Nations governance;  

5.14 Financial and human resources;

6. Specific Review Items:

The Review will address the following issues specifically, as part of the above mentioned analysis:

6.1 Funding of the NNADAP (Prevention and Treatment)

6.1.1 Past and current funding methods for NNADAP  
6.1.2 Strengths/weaknesses of the NNADAP funding formulae  
6.1.3 Funding principles  
6.1.4 Models of different funding methods or systems  
6.1.5 Recommendations on the funding of the NNADAP components  
6.1.6 MSB breakdown of program resources  
6.1.7 NNADAP financial relationship to other programs (e.g. NIHB)  
6.1.8 Community workload increase system (CWIS) funding formula

6.2 Standards and Accreditation process for NNADAP (Prevention and Treatment)

6.2.1 Identification of programs or services that would require standards.  
6.2.2 Existing standards for substance abuse programs (national and international)  
6.2.3 Possible accreditation models and processes  
6.2.4 Recommendations

6.3 Training (Prevention and Treatment)

6.3.1 Review training, accredited or other related standards for the NNADAP workers  
6.3.2 Review of training needs of the NNADAP workers
6.3.3 The types and availability of alcohol & other substance abuse training
6.3.4 Review of the training approach for the NNADAP  
6.3.5 Recommendations

6.4 NNADAP Data Collection and Reporting Systems (Prevention and Treatment)

6.4.1 Definition and review of the NNADAP information system  
6.4.2 Identification of the potential users of the NNADAP information system  
6.4.3 How is the existing system specifically meeting and not meeting the needs?  
6.4.4 What are the alternative/solutions to meeting those needs?  
6.4.5 Should and can the new system be part of/or be compatible with other national health data collection system (e.g. the health information system).  
6.4.6 Recommendations on the type of information needed and systems for the NNADAP projects.  
6.4.7 Community workload increase system data collection methodology.

6.5 Transfer Policies and Practices (Prevention and Treatment)

6.5.1 Current approaches being taken in the Regions with respect to NNADAP transfers  
6.5.2 Impact of current transfer policies on NNADAP  
6.5.3 Recommendations

6.6 Relationship of NNADAP Projects/Services with other Community Based Services

6.6.1 To what extent is NNADAP currently involved with other programs and services at the community level  
6.6.2 Identification of advantages and disadvantages to coordinate NNADAP with other community based services  
6.6.3 Recommendations

6.7 NNADAP Research and Development

6.7.1 What is and was the nature and extent of community based and national NNADAP research and development activities  
6.7.2 How do these activities relate to the delivery of NNADAP programs and services  
6.7.3 Can and should research and development activities and outputs be more effectively linked to the delivery of NNADAP programs and services  
6.7.4 Are there other viable alternatives to the present approaches being taken with respect to NNADAP research and development

6.8 NNADAP Evaluation Practices and Procedures

6.8.1 What practices are followed at community, regional and national levels  
6.8.2 What performance indicators/measurement tools are used  
6.8.3 Are current practices adequate - deficiencies  
6.8.4 Are there best practices of other community oriented Drug and Alcohol Abuse Treatment/Prevention Programs and other MSB programs that could be adapted to NNADAP
6.8.5 Recommendations

6.9 NNADAP workers scope of duties

6.9.1 What is the scope of practice for NNADAP treatment and prevention workers?  
6.9.2 Roles and responsibilities of NNADAP treatment and prevention workers.  
6.9.3 What was the original role of the NNADAP treatment and prevention workers?  
6.9.4 Has the NNADAP treatment and prevention worker's role changed? (diminished or increased)
6.9.5 Recommendations on the scope of duties for NNADAP and treatment workers.

7. Management Strurcture:

A Steering Committee will be established to oversee the NNADAP Review process. Program technical support and coordination to the Steering Committee will be provided by the Health Programs Support Division of the First Nations and Inuit Prevention Initiatives (FNIHPD).

An outside consulting firm will be hired to carry out the actual review of NNADAP.

8. Composition and Responsabilities:

The NNADAP Review Steering Committee is based on an equal partnership approach between First Nations and Medical Services Branch. The NNADAP review should be conducted in the spirit of partnership and full transparency of information.

The Steering Committee is co-chaired by the Director General of First Nations and Inuit Health Programs Directorate and a First Nations representative nominated by the Society of Aboriginal Addictions Recovery (SOAAR).

Membership shall include one Medical Services Branch Regional Director, one representative from the Regional NNADAP consultants and two representatives of the Assembly of First Nations.

The Steering Committee will be responsible for:

• development of a Terms of Reference and general milestones for the review process;
• contractor selection;
• monitoring the review process and providing general guidance to the contractor;
• sign-off on review deliverables;
• liaising with Branch senior management in headquarters and the Regions and other key stakeholders concerning review activities;
• presenting the final report to the Branch Executive Committee.

9. Meetings and Resourcing of Steering Committee Activities:

The Steering Committee will meet or teleconference monthly depending on agenda requirements. The quorum for the meetings will be five out of six members.

Travel related costs of the MSB representatives on the Steering Committee will be covered through their respective Regional County Municipalities (RCMs). The Health System and Policy Division (HSPD) of the First Nations and Inuit Health Program (FNIHP) will be responsible for travel related costs of non-public servants participating on the Steering Committee.

10. Review Methodology:

The contractor in consultation with the Steering Committee, will:

10.1 Develop a framework for the conduct of the review, including a detailed workplan;  

10.2 Provide written monthly progress reports to the NNADAP Review Steering Committee;  

10.3 Use culturally sensitive data and information collection methodologies which also take into consideration and respect confidentiality and privacy requirements. Methodologies will include:

• Determination of data and information collection requirements;
• Identification of collection samples that will cover the major areas of emphasis of the NNADAP and will be representative of all the MSB regions including Yukon and the Northwest Territories. (It should also include the same programs that were surveyed during the 1989 evaluation and transfer communities);
• Determination and development of data collection strategy and related work instruments;

10.4 Present draft and final reports to the NNADAP Review Steering Committee and Branch Executive Committee.