National Native Alcohol and Drug Abuse Program (NNADAP) -
General Review 1998 - Final Report
Discussion of General Trends
In examining the outcomes of this review, there are several trends, which
are+ present within the overall elements of the review, which should be highlighted.
North-South Issues
In visiting communities, there were several variables for northern or remote
communities, which create unique challenges to addictions programming in particular,
and in general to other health and social services programs.
Transportation costs are the most obvious of the variables which impact programs
and limit choices both for individual residents and for program staff. However,
transportation has other impacts, which are not totally related to the increased
cost of providing services. At times, issues such as the location of the airstrip
have major impacts on the ability of the community to deal with
addiction issues. For example, in Garden Hill, Manitoba, the community has
to use an airstrip, which is not on reserve. Aside from the complications arising
from having to shuttle across the lake, this also makes it impossible for the
community to prevent alcohol and drugs from being brought into the area and
thus into their community. Location of the law enforcement and detention facilities
can also be seen as having an impact on the community's ability to deal
with problems in a consistent and appropriate manner.
Staff recruitment presents varying types of problems. For example, depending
on the size of the community and its history of post-secondary education, there
may not be a pool of potential employees within the community who would meet
the entry requirements for NNADAP sponsored training programs. Further, once
persons are trained, a combination of lack of salary adjustment for isolated
locations and comparatively low salaries generally mean that the person in
the position is recruited to other higher paid jobs. For those communities
who recruit from other communities to fill positions, such persons tend to
leave after completing training. Obviously, there are exceptions and there
were numerous examples of dedicated people whom we met during the field visits.
Observations on areas of challenge identified in the review tend to be accentuated
in northern or remote communities. By their nature, communication issues and
support, training, access to provincial services, and availability of beds
has more of an impact. At the risk of generalizing, it could also be stated
that the emphasis on treatment within northern communities is also an issue,
which has implications for workers in the field.
Focus on Treatment
To a great extent, the focus on treatment needs for individuals within communities
tend to dominate the agenda for the NNADAP program. This circumstance continues
despite many efforts taken on the part of key decision-makers and programmers
such as NNADAP Headquarters personnel, regional First Nations organizations,
training institutions and other key players, to develop other emphasis. For
example, considerable effort was applied to develop a prevention framework
for the NNADAP program utilizing key stakeholders.
It is important to clarify that the above statement is not intended to be
a criticism of the program or its personnel. Rather, it should be stated in
almost all cases there are real treatment needs within the community, and that
those needs are felt directly by the leadership. The leadership, in turn, expect
the alcohol and drug abuse worker to directly provide services, or at least
to be the key individual who can assist a person or family in a time of need.
This dilemma is not unique to addictions programs. The same issue and expectations
also are present in other health and social programs. For discussion purposes,
an example which illustrates this circumstance, is a person suffering from
complications of diabetes such as potential amputation. The best advice and
scientific evidence available have shown that the best approach to dealing
with Type II, adult onset diabetes is to delay or prevent the onset of diabetes
through a combination of exercise, nutrition and other lifestyle approaches.
However, even such practices are not a guarantee that the individual will not
suffer from diabetes or its effects. For those persons diagnosed with Type
1 or early onset diabetes, the aforementioned measures will not affect onset,
but rather may mitigate the long-term impact of diabetes.
A health professional who ignores the treatment needs of the person described
above will do real damage to the person and also potentially diminish his or
her credibility within the community. The challenge in this situation is to
change the community's perceptions about diabetes and to implement the
measures described above which will have payoffs for the entire population.
In doing so, there will have to be careful planning, use of key individuals
to promote proper lifestyle behavior, and proper educational activities targeted
at groups such as the community leadership.
The parallels to addictions in the community are unmistakable. The challenge
for NNADAP as an overall system is to recognize the current circumstances,
which reflect a certain requirement for treatment while strategizing about
the means of moving the balance of services towards a prevention and health
promotion emphasis. In doing so, it must be recognized that wellness and health
promotion need to be orchestrated much like a social or political movement.
An example of an extremely effective approach is the National Addictions Awareness
Week (NAAW) coordinated by the Nechi Institute.
It must be recognized that the most effective means to promote such a movement
within the First Nations and Inuit populations of Canada is through the support
of existing aboriginal institutions and the support of new initiatives such
as an Aboriginal Health Institute and centers of excellence.
Less dramatic but also effective in supporting health promotion, prevention
and early intervention are such measures as: establishing well publicized annual
goals for NNADAP (or for Health Canada), by hosting conferences to support
health promotion and prevention concepts, and by developing public relations
and communications material.
Impact of other health and social cutbacks
The NNADAP financial history has been reviewed as part of this study. However,
this financial review only examines one dimension of a complex financial picture.
It must be recognized as well that there are cumulative effects of other fiscal
measures taken by a variety of jurisdictions. Some of these measures or decisions
are as follows:
Federal
The Department of Indian and Northern Affairs (DIAND), followed by Health Canada, eliminated per diems for individual patients
in treatment programs. Originally, such per diems were intended to be a supplement
for individual clients to pay for sundry items such as personal hygiene products.
These costs were subsequently either passed on to the client or absorbed by
the treatment program.
Non-Insured Health Benefits Program has controlled costs by instituting a
series of reductions as follows:
- Out of country treatment services and Non-NNADAP treatment programs have
for all intents been eliminated
- There are restrictions on referral of clients out of the region even if
attending a NNADAP treatment program.
- Medical transportation has been converted to a program and will be transferred
to community control
The envelope funding concept for Health Canada has eliminated the practice
of approaching central agencies to examine individual programs' needs
and has resulted in the discontinuance of the Community Workload Information
Systems (CWIS).
The Human Rights Tribunal rulings on compensation for various occupational
groups such as nurses and the Community Health Representatives (CHR)s have caused federal departments to eliminate
salary figures in contribution and transfer agreements. This makes it difficult
to mount arguments based on wage parity since there are no references to wage
levels.
There has been minimal or limited growth in contribution funds in the past
five years due to federal constraint. NNADAP has the additional disadvantage
of not receiving incremental increases in the period immediately prior to this
period of constraint.
In addition, some of the reductions referred to in the NNADAP financial study
have been carried out to respond to fiscal reduction targets imposed either
by the Government of Canada as part of its overall reduction plan or by Health
Canada to deal with internal fiscal pressures.
Provincial
Provincial health care reform has reduced or eliminated many services, which
directly or indirectly have an impact either on treatment programs or individual
clients. Some examples of this include:
- Reduced availability of hospital beds which affects the availability of
detoxification services
- Most provincially insured services programs limit or eliminate referrals
to out of province or out of country treatment programs
- Most provinces have also eliminated payment for medical checkups. This
sometimes is an immediate barrier to treatment
since costs generally are in the $100 range.
Due to reductions in the rate of growth of Federal/provincial transfer arrangements,
provinces have concerns about providing health and social services to First
Nations and Inuit people who are constitutionally defined as a federal responsibility.
Reductions in mental health and trends towards de-institutionalizing mental
health patients are creating additional pressures in programs such as NNADAP.
Federal and Provincial
Early release programs for federal and provincial penal institutions and alternative
sentencing are creating additional demands for treatment for which there has
not been a corresponding investment of funding by these respective jurisdictions.
Summary and opportunities for advancing issues
As described above, it can be readily seen that there are complex fiscal challenges
facing NNADAP as a program, and as part of the health and social services system.
Accordingly, there will have to be complex and well developed strategies for
dealing with the obvious need for additional resources identified in this study.
A key example of this is the issue of wages. This issue was identified by
a vast majority of individuals within the program. However, dealing with the
issue of appropriate wages will demand a carefully developed strategy to achieve
progress. To simply accept the statement from Health Canada that there is no
funding available is not productive. There are a number of fiscal implications
arising from this report. It will require a true partnership approach between
Government of Canada and First Nation and Inuit people to deal with these challenges.
An effective partnership also will require the development of a careful and
realistic strategy to ensure that the necessary supports are provided to the
NNADAP in order that First Nation and Inuit communities will be able to deal
with the challenges of today and the future.
In order to support necessary program changes, funding criteria should be
designed to reinforce adherence to essential areas of development raised by
this report. For example, providing funding incentives or flexibility or other
strategies would make it desirable to adhere to National Standards, to implementing
proper data systems, to evaluate programs or to attain accreditation as a worker.
As a first step, it will be extremely important to exhibit a renewed commitment
by both Health Canada and First Nation and Inuit organizations to the support
of programs dealing with the addictions issues faced by communities.
In developing and carrying out the details of this strategy, there are a number
of considerations and opportunities that should be examined related to the
wage issue and other financial issues raised by the report.
Obviously, Health Canada should review the detailed financial report and determine
the potential to reallocate resources to deal with the areas, which have been
adversely affected by budget reductions over the years.
Similarly, First Nation and Inuit communities should also examine themselves
from a similar perspective as may be illustrated by the following possibilities:
- First Nation and Inuit communities have had a series of new programs and
initiatives within mental health and mental wellness over the last 5 years
for which the respective First Nation or Inuit community has considerable
latitude in spending. Brighter Futures and Building Healthy Communities could
be considered for supporting various elements within an overall community
wellness strategy, which could include NNADAP.
- Individual First Nation communities should also review funding agreements
to determine whether available salary dollars were provided to NNADAP workers.
In some cases funding was split into two workers or the full salary was not
given to workers.
- Communities under transfer agreements have the opportunity to review salaries
as per their internal requirements and budgetary constraints.
Health Canada in partnership with First Nation and Inuit organizations should
also jointly strategize opportunities to deal with addictions needs through
resources available in other jurisdictions. The following is a list of potential
opportunities from the federal, provincial and private sectors:
- Federal Crime Prevention fund which currently has no criteria for First
Nation participation.
- Similarly, the Proceeds of Crime legislation could be examined for areas
of potential interest and benefit for communities.
- Studying the implications of early release and alternative sentencing
programs and negotiating with federal and provincial sources for funding
to support these efforts.
- Casino profit sharing or seeking funding from federal or provincial gambling
sources to deal with issues relating to gambling addictions.
- Use of resources under tobacco addictions programs at the federal and
provincial level.
- Consideration could also be given to the pros and cons of soliciting funds
from tobacco companies and breweries to deal with various issues and programs.
- Developing a definite role for addictions programs in the healing and
wellness strategy.
- Developing arrangements by which NNADAP programs could be part of EAP
services for First Nations and Inuit communities.
- Developing fee for service arrangements for which training can be provided
to NNADAP workers as well as other health and social services workers at
the community level.
- Examining the viability of acquiring funds under provincial programs.
- Examining Non-Insured Health Services to determine opportunities to develop
mutually beneficial strategies such as prescription drug abuse prevention,
intervention, and treatment programs.
In conclusion, while there are many needs, there are also opportunities to
deal with these needs. However teamwork, effective strategy, and follow up
will be essential for success.
Evolution of Aboriginal Self Government
The concept of government to government relationship with First Nations and
Inuit and the realization of new partnerships as a result of the Royal Commission
on Aboriginal peoples will have a real impact on the developments recommended
in this report; and more importantly, the style in which these recommendations
are implemented.
In the federal response to the RCAP report entitled "Gathering Strength-
Canada's Aboriginal Action Plan" there four objectives contained
which were intended to serve as the first step in the long process of establishing
a working government to government relationship between the federal government
and First Nations governments. These objectives are as follows:
- Renewing the partnership
- Recognizing and strengthening First Nations governments
- Equitable and sustainable fiscal relationships
- Supporting stronger First Nations communities and people
As may be seen from this type and style of response, there will be implications
for the follow-up to the NNADAP review to assure that such responses are consistent
with current trends in Federal -- First Nations relations. However, it
is important to state that these recommendations have been developed with this
overall philosophy in mind, and that there is an explicit recognition of the
need for First Nations and Inuit people to be empowered in dealing with their
health and social issues.
Some examples of areas affected by this style of approach are as follows:
- Examining the issue of implementation of standards, information systems,
and evaluation will have to be done from the perspective that First Nation
and Inuit organizations will have to be explicitly involved with the design
and approval of such developments.
- Creation of First Nation and Inuit Institutions will be a key strategy
in implementing change and promoting program concepts within communities.
Control and ownership of such program elements formerly seen as controlled
by Health Canada such as accreditation processes and systems for collecting
data will be the most important element in acceptance by communities.
- Increasing levels of resources are now under First Nation control and there
is a likelihood that this trend will continue. First Nation and Inuit organizations
and aboriginal organizations, in general, will have an increasing role to
play in determining government funding priorities. There will be an interest
by both parties in moving towards province like transfer agreements with
minimum requirements or standards.
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