National Native Alcohol and Drug Abuse Program (NNADAP)
General Review 1998 - Final Report

Results of the NNADAP Review

NNADAP Funding

The scope of this review includes regional and national expenditures on NNADAP over the time period 1983-84 to 1996-97 in the broad categories of treatment, prevention, training, research, management and support. It is impossible to reconstruct in detail, financial expenditures of the 1980s because different financial recording procedures were used compared to the present day. Therefore, for contribution expenditures of treatment, prevention and training in the 1980s, this review was provided with budgeted amounts rather than actual expenditures. Although actual expenditures in the management and support category were provided, a breakdown of these expenditures into operating and salary dollars was not available. Other limitations to this review include:

• There is not a separate accounting of capital expenditures provided, with the exception of 1990-91. Capital costs are likely included with general treatment expenditures, however some administrative expenditures could include capital.
  
  
• There is not a separate accounting for renovation expenditures. Although this was a separate line item in the NNADAP plan set forward in 1982, the level of detail afforded this review precludes any analysis of the level of funding set aside or used to maintain the treatment center infrastructure.
  
  
• There is not a separate accounting for the regional commissions and national advisory board or the 1989 NNADAP review.
  
  
• Training expenditures were not separately coded in the regional aggregate activities for the time period 1983-84 to 1989-90. Also, in the 1990s, two regions incompletely coded training expenditures.
  
  
• As the scope of this review was limited to NNADAP, a more holistic look at the expenditures of all mental health programs and services under the mandate of Medical Services Branch (MSB) was not possible.

The NNADAP financial profile has been affected by two major events: the 1992 decentralization of funds to the regional offices of MSB, and the negotiation of transfer and integrated agreements which has further devolved program control to the community level. MSB headquarters retained the resources for research and development in the 1992 reorganization, and continues to play a consultative, policy setting role, as well as centralizing information resources, developing guidelines, standards and educational resources, and evaluating the program.

Four communities comprising the Nis'ga Health Board were the first to negotiate NNADAP transfer in 1988-89. Since that time to 1996-97, 95 agreements (transfer or integrated) have been struck involving 202 communities (see Table I below). Integrated agreements accounted for $1.7 million of NNADAP funds, and transfer agreements for an additional $6.7 million. These funds, which were formerly prevention and training resources in contribution agreements, are no longer included in aggregate totals for the NNADAP program. The transfer of two treatment centers has involved another $1.8 million.

The growth of NNADAP in the l980s, although significant, was not as large as the First Nations and Inuit Health Program overall. NNADAP experienced 41% growth from l985-86 to l990-91, largely as a result of transfers and integrated agreements; NNADAP had declined by 10.7%. The Community Health Activity of First Nations and Inuit Health Program (FNIHP), which includes NNADAP as one of the component, has also undergone significant transfer. However, there is an increase from l8.6% of the envelope to 27.1% between l990-91 and l995-96. In absolute terms, expenditures have more than doubled in this time period, in contrast to the decrease in NNADAP expenditures of l0.7% for the same time interval.

NNADAP has never experienced funding cutbacks in its fifteen-year history although research and development in particular has not been funded to the level that was planned. Extra funding was provided as part of the Community Workload Increase System ($2.8 million in l989-90) and to adjust for increased clients as a result of Bill C31, which granted status to First Nation persons ($9.3 million over 5 years).

As the program matured, the allocation of funding among the different components of NNADAP has varied throughout the fourteen years that were included in this review. Prior to NNADAP, the total budget in the National Native Alcohol Abuse Program (NNAAP) was $8 million per year with prevention and training accounting for 75% of the budget and treatment a distant second at 13% of the budget. Program developers had projected that in l985-86, prevention would decrease to 43% of the budget; however this target was not reached, and the prevention component still expended 58% of the total NNADAP budget. From l985-86 to l990-91, the total NNADAP expenditures increased from $35.1 million to $53.3 million. Treatment expenditures increased at the expense of prevention and training, from 35.5% of funds in l985-86 to 42.9% in l990-91. Prevention and training resources dropped to 44.2% of the budget. As transfer was not a significant variable in 1990-91, the increase in treatment resources can be attributed to enrichment in this component, and the completion of all the planned treatment centers.

In 1995-96, treatment costs claimed a larger share of the NNADAP envelope at 54.5%; however this is now more likely due to the emphasis placed on the transfer of prevention and training resources to the community compared to few transfers involving treatment center resources.

Treatment

Currently there are 49 treatment centers in NNADAP providing approximately 695 beds. It is difficult to obtain an up-to-date figure on the number of beds in the program as some treatment centers may have converted in-patient resources to outpatient spaces, closed beds or may operate provincially funded beds in the facility. The current level is 5% less than the projected total of 730 beds at program maturity (extra 590 beds were to be added to the 140 beds that existed in 1982). Reasons cited for not reaching this target relate to the increased emphasis placed on outpatient services and aftercare, a direction, which was supported by the recommendations of the 1989 national NNADAP review.

Nationally, treatment contributions were $6.4 million in 1983-84, increasing to $16.9 million in 1989-90. In the 1990s, treatment contributions continued to rise to $23.8 million in 1996-97. Annual per capita expenditures were stable, ranging from $38.02 to $38.95 per person, with the exception of 1994-95 ($34.42) when the Sagkeeng Treatment Center in Manitoba was transferred (removing approximately $2 million from the NNADAP envelope).

Some regions have covered per diem treatment costs of private treatment centers in addition to funding NNADAP centers, often through use of non-insured health benefits (NIHB). The practice of using NIHB resources in non- NNADAP centers was reviewed in 1995 at MSB headquarters. With the implementation of regional envelopes, the regions were notified that they were no longer able to charge NNADAP-type expenditures to NIHB. Regions weregiven the option of transferring resources out of NIHB to cover per diems at non- NNADAP centers but few took advantage of this option. This resulted in non- NNADAP operating expenditures dropping in 1996-97 to $689,980 from $2,638,890 a year earlier.

When compared to the level of treatment expenditures recommended by the NNADAP planners in 1982, actual per capita treatment expenditures have lagged behind. It was planned that in 1986-87, $71.50 per First Nation and Inuit person over the age of 15 would be expended on treatment(Based on the on-reserve population) In actual fact, the per capita expenditures reached an estimated $56.03, which was 78.4% of that deemed necessary to meet demand. Not only was the actual amount of treatment expenditures less than that projected by the Cabinet document ($10.1 million (The actual treatment expenditures recorded is $14.11 million, however capital costs are included in this total. These costs have been estimated at $4 million (see full text of report for description)) compared to $12.5 million), the eligible population aged 15 years and over was underestimated.

A similar calculation for 1995-96 of per capita treatment expenditures for persons over 15 years of age results in $80.83 for treatment expenditures in NNADAP. When presented in 1986 dollars to adjust for inflationary factors, the per capita amount is $59.60, which is 83.4% of the 1986-87 $71.50 benchmark.

A regional analysis of bed occupancy and use of additional resources (through NIHB or other operating dollars) shows that there is not a relationship between bed occupancy and increased use of private treatment centers. Regions with the lowest occupancy rates had the highest use of private treatment centers. This review has not conducted an in depth analysis of the issue to identify the reasons for this finding. Possible explanations include need for treatment services such as solvents and other special needs; the desire of clients to attend treatment centers close to home rather than travel to a NNADAP center; variability in the calculation of bed utilization rates; and inefficient utilization of the NNADAP centers' beds.

Treatment costs per client day are highly variable among the regions, and may be related to the size of treatment centers, geographic location, differences in programs offered, and differences in regional policies regarding contribution agreements. In the time period 1989-90 to 1995-96, the highest overall treatment costs per client day were seen in the Atlantic region, which had a mean of $213.18 for the seven years reviewed and the highest individual annual cost of $399.29 in 1991-92. The three prairie regions had the lowest client costs, with Manitoba realizing the lowest average cost of $75.33. Overall, the national daily treatment costs over this time period ranged from $121.14 to $159.52 with a mean of $138.47.

Prevention, Maintenance and Training

In NNADAP, expenditures for prevention and maintenance cover operating costs for a range of community information, advocacy, self-help, group therapy and crisis intervention services. In the NNADAP Cabinet paper, training was divided into two categories: staff development and ongoing refresher and orientation courses. No breakdown between these two components is available for the period 1983-84 to 1989-90. The expansion phase of the 1980s is reflected in the steady increase in regional funds accorded to prevention and training. These resources totaled $14.5 million in 1983-84, increased to $26.8 million in 1987-88 and ended the decade at $24.9 million.(This decline in funds at the end of the decade to 24.9 million (1989-90) is due to the transfer of resources to the Government of the Northwest Territories and to decreases in the FNIHP directorate.)

Prevention, maintenance and training expenditures were forecasted by NNADAP planners at $17.6 million in 1986-87 in a mature program. Using the on-reserve 15 years and older population which was predicted to be 175,000 persons for this year, the projected per capita expenditures in 1986-87 were $100.60 per person. The historical budget data provided to this review suggests that $25.9 million was expended in prevention and training in l986-87. Using the actual population, contribution expenditures in prevention and training were $130.62 per person, which was 29.9% higher than planned.

Prevention and training expenditures are itemized separately for the period 1990-91 to 1996-97. In 1990-91, prevention expenditures were $22.4 million and comprised 42% of NNADAP expenditures nationally. They peaked in 1992-93 at $27.4 million, and by 1996-97, decreased to $16.4 million or 37.4% of total NNADAP expenditures. At the regional level, all regions showed an increasing or stable level of prevention expenditures until the mid 1990s, at which time these expenditures started to fall, due to the negotiation of transfer and integrated agreements with communities. The effect of these transfer agreements on the non-transferred population remaining in the NNADAP funding envelope was examined by this review, by calculating the regional per capita expenditures (On and off reserve population from the Indian Register was used in the per capita calculation.) for the years 1991-92 and 1995-96. 1991- 92 was chosen because few transfers had occurred involving only 8% of the First Nations population. By 1995-96, the proportion of transferred communities had more than quadrupled to 35% nationally.

The regions vary greatly in individual per capita amounts for both years, due to the varying population sizes and the formula used to allocate funds whereby 25% of the available funds was distributed equally among all regions. For both years, a similar per capita spread among regions is obtained. For example, in 1995-96, the range was from Alberta's per capita allocation at $37.74 to $147.58 in the Atlantic regions. Analysis of the changes in the per capita amounts between 1991- 92 and 1995-96 suggests that the per capita level of resources remaining after transfer in a region becomes proportionally larger. A potential explanation of this is the trend for larger communities or groups of communities to take transfer. This makes it appear that there is a higher per capita level of resources available after such transfers. As the prevention expenditures in the per capita calculation are solely contribution agreements and do not include regional management and support expenditures, the size of the remaining regional office during the transfer phase should not affect these per capita figures.

Research and Development

In the NNADAP Discussion Paper of 1982, research and development was listed as the fourth component, after treatment, prevention and training. It had been identified as a gap in the previous NNAAP demonstration project. Accordingly, the new NNADAP design incorporated funding for pure and applied research studies which were intended to add to the knowledge of substance abuse problems among Aboriginal people. This was intended to facilitate effective interventions and prevention strategies and the development of a national case record and information system, which would provide better monitoring and evaluation of individual cases as well as assessment of program effectiveness.

NNADAP budget forecasts incorporated a research component, calculated as 5% of the treatment and prevention/maintenance budgets on an annual basis. The research component would increase steadily from zero in year one of the strategy to approximately $1.5 million in year five.

Financial data shows an erratic approach to research and development, with little attention attributed to this component in the 1980s. The decade of the nineties started out with approximately $400,000 as the annual research budget. The peak year for research and development was 1992-93 when almost $1 million was provided for projects and studies. A decision was made following the 1992 devolution of NNADAP funds to the regions to discontinue communitybased research. The next three years averaged $600,000 annually, until 1996- 97 when funding fell to just short of $100,000. On a percentage basis funding for research fell from a planning figure of 5% of the total base to .2%. This is 1/25 of the amount estimated in the original program design.

Management and Support

In the financial data provided for the 1980s, there is no breakdown between salary and operating costs in the category of management and support and two regions show incomplete expenditure data. The last year with complete regional information in that decade is 1987-88, which recorded a $2.6 million expenditure in management and support costs. In the period of the nineties, management and support expenditures have declined from $6.4 million in 1990- 91 to $1.9 million in 1995-96. In 1996-97, these expenditures have increased by about 5% to $2.0 million from the previous year.

The pattern of salary expenditures in both headquarters and the regions for the time period 1990-91 to 1996-97 is variable. Despite the increasing number of transfers and integrated agreements, only Ontario, Atlantic and Pacific regions show a significant decrease of salary costs in the latter part of this time period. Saskatchewan, which had over 60% of its population under NNADAP transfer and integrated agreements by 1995-96, has had an increasing level of salary expenditures since 1991-92. Alberta, with essentially a non-transferred population, has had fairly stable salary expenditures. The reason for sustained salary expenditures even in a transfer environment may be due to regional policies which retain a full NNADAP position even if the NNADAP budget is reduced considerably, as NNADAP staff often have other responsibilities for related programs such as Brighter Futures.

In the FNIHP directorate, salary expenditures remained high from 1990-91 to 1994-95 at approximately $400,000 per year, even though only one full-time staff person was connected to the program during the latter part of this time period. With the discontinuation of the policy of dedicated staff for individual programs in the FNIHP Directorate, portions of many different staff positions make up a salary component of a program and it is impossible from these financial records to reconstruct the actual number of full time equivalents (FTEs) at headquarters that are associated with a program such as NNADAP.

In 1995-96, salary expenditures at the FNIHP Directorate decreased by approximately $360,000 to $75,672 and then bounced back to $279,196 in 1996-97. Nationally, salary levels decreased by 14% from 1990-91 to 1996-97, which is slightly less than the overall decrease in NNADAP expenditures (nontransferred) of 18% for the same time period.

As illustrated in Table 2 above, the number of FTEs associated with the entire NNADAP program has fluctuated among the years reviewed from 28 to 65, and the mid 1980s show the highest number of staff positions with the exception of 1993-94 which has 65 FTEs recorded. In the 1980s, an average of 2.0% of all FNIHP positions was attributed to NNADAP. This declines marginally to 1.9% in the 1990s (or 1.6% if 1993-94's high percentage of 3.4 is excluded) suggesting that the decrease of staffing in NNADAP overall is unremarkable when compared to other programs in FNIHP.

When salary and operating expenditures are considered together in the 1990s, a significant consistent decline is seen in contrast to the fluctuating levels seen with annual salary allocations. Nationally, salary and operating expenditures have decreased from a high of $3.2 million in 1991-92 to $1.8 million in 1996-97, a 43% drop. One-half of this decline relates to decreased expenditures in FNIHP directorate.