Health

Anti-Indigenous Racism in Health Systems

The Government of Canada is committed to ending anti-Indigenous racism in our health systems in a way that is informed by the lived experiences of Indigenous Peoples and based on the recognition of the rights of Indigenous Peoples. With the support of Health Canada and Crown-Indigenous Relations and Northern Affairs, Indigenous Services Canada led the planning and coordination of 4 national dialogues on addressing racism experienced by Indigenous Peoples in Canada's health systems from October 2020 to January 2023. The Government of Canada has publicly acknowledged the impact of colonization on Indigenous health at multiple forums including the third national dialogue on anti-Indigenous racism in health care held in June 2021.

Discussions at the national dialogues helped identify many of the root causes and critical gaps that need to be addressed to ensure Indigenous Peoples have access to high quality, culturally-informed health services, and to ensure health care systems are free of racism and systemic discrimination against Indigenous Peoples.

The Federal Pathway to Address Missing and Murdered Indigenous Women, Girls and 2SLGBTQI+ People reaffirms the Government of Canada's commitment to transforming health service delivery to an Indigenous-led model, to address anti-Indigenous racism in health systems, improve cultural safety across the various stages of health service delivery, support the advancement of Joyce's Principle and to convene partners on a continued national dialogue on accountability and change.

Ultimately, these actions will contribute to health systems free of racism and discrimination and will lead to better health and wellness outcomes for Indigenous Peoples, particularly Indigenous women, girls, 2SLGBTQI+ people and their children and families.

Health Transformation

The Health Transformation initiative supports tripartite processes between First Nations-led health organizations (representing a number of communities), the Government of Canada, and provincial governments. The Health Transformation initiative transfers federally funded health services to the control of First Nations so that they can design and deliver health programs that respect distinct cultural practices and respond to the needs of their communities.

This initiative acknowledges that in order to make significant improvements in health service delivery and outcomes, the role of the federal government in health must change by establishing new partnerships that are based on reciprocal accountability, so that decisions over health for First Nations can be made by First Nations. Health Transformation aims to increase First Nations' control in the design, delivery, and management of health services, to enable improved coordination with provincial/territorial health systems, and to create the conditions needed to address health inequities faced by First Nations people.

One of the outcomes of the Health Transformation initiative has been the establishment of partnerships and recognition of the negative impacts of federal and provincial policies and programs on Indigenous communities through the Memorandum of Understanding and Agreements-in-Principle under discussion with Indigenous partners.

Distinctions-based Indigenous Health Legislation

The Government of Canada is committed to working in partnership to continue to advance the priorities expressed by Indigenous Peoples about their health and to improve access to high quality, culturally safe health services. In 2019, the Government of Canada made a commitment to support engagement with Indigenous Peoples to identify priorities and hear how distinctions-based Indigenous Health Legislation might help create the change necessary to address health gaps and inequities. The commitment extends to working with First Nations, Inuit, and Métis partners, as well as Indigenous partners with intersectional lenses, to co-develop potential legislative options that advance the priorities identified through engagement.

The Minister of Indigenous Services publicly launched the engagement process on Indigenous health legislation on January 28, 2021, during the second national dialogue on anti-Indigenous racism in health care. The engagement process wrapped up in fall 2022, and a national summary report, What We Heard: Visions for Distinctions-based Indigenous Health Legislation publicly available.

Jordan's Principle

Jordan's Principle is a legal obligation, described by the Canadian Human Rights Commission, that ensures all First Nations children living in Canada can access the products, services and supports they need. Jordan's Principle helps to ensure that all First Nations children can access the health, social, and educational services they need.

Recent budget investments

To build on the progress made through the Budget 2021 investment to take action to foster health systems free from racism and discrimination where Indigenous Peoples are respected and safe, Budget 2024 proposes to provide $167.6 million over 5 years, starting in 2024 to 2025, to combat anti-Indigenous racism in health care to help ensure Indigenous Peoples are treated with the respect and safety they deserve. These investments will continue supporting patient advocates, health system navigators, midwives, and birth support workers, as well as initiatives to increase Indigenous representation in the health professions.

Budget 2022 provided $4 billion over 6 years, starting in 2021 to 2022, to ensure First Nations children continue to receive the support they need through Jordan's Principle. Budget 2023 provided an additional $171 million in 2022 to 2023 to ensure First Nations children continue to receive the support they need through Jordan's Principle.

Budget 2023 reaffirmed the Government of Canada commitment to invest $2 billion over 10 years through a new Indigenous Health Equity Fund to address unique challenges Indigenous Peoples face when it comes to fair and equitable access to quality and culturally safe health care services. Funding will be provided to First Nations, Inuit, and Métis on a distinctions basis.

Building upon Budget 2018 and Budget 2021 investments, Budget 2024 proposes to provide $104.9 million over 5 years, starting in 2024 to 2025, for health transformation initiatives to support First Nations self-determination in the design and delivery of health services in their communities.

Recent progress

Since 2018, significant progress and momentum has been made related to self-determination and service transfer as there are currently 6 sub-regional Health Transformation projects and tables (Keewatinohk Inniniw Minoayawin Inc. and Southern Chiefs Organization in Manitoba, Tajikeimɨk in Nova Scotia, Nishnawbe Aski Nation in Ontario, La Commission de la santé et des services sociaux des Premières Nations du Québec et du Labrador in Quebec, and Battleford Agency Tribal Council in Saskatchewan). The Keewatinohk Inniniw Minoayawin Inc., the Southern Chiefs Organization, and Tajikeimɨk are anticipating concluding Agreements in Principle in 2024 to 2025, which will lay out the conditions and governance structure that will be in place when the transfer of responsibility occurs. Work on Health Transformation in collaboration with First Nations continues to take place.

Starting in fall 2022, Canada established distinctions-based working level groups with Indigenous partners, or co-development tables, to meet regularly and translate what was heard through engagement on distinctions-based Indigenous health legislation into proposed legislative options. In total, 14 separate co-development tables were established with First Nations, Inuit, and Métis partners, as well as Indigenous partners with intersectional lenses, between October 2022 and June 2023. Participation in the co-development tables offered another opportunity for partners to help identify potential federal legislative and policy measures that would support Indigenous-led and distinctions-based approaches to health.

Informed by the discussions and input from partners, ISC prepared a Key Legislative Elements document and shared it widely to all partners for review and feedback. The Key Legislative Elements document presents a high-level compilation of potential legislative and policy options that are being considered. A significant amount of feedback was received from First Nations, Inuit, and Métis partners, as well as Indigenous partners with intersectional lenses on the Key Legislative Elements document during the month of September 2023. In just over 3 weeks, ISC facilitated 27 distinct dialogues with partners and received 39 separate written submissions in reaction to the Key Legislative Elements document.

Between July 1 2016 and March 31, 2024, Jordan's Principle approved more than 4.86 million products, services, and supports for First Nations children.

Between April 1, 2019 and March 31, 2024, the Inuit Child First Initiative approved 207,433 products, services, and supports for Inuit children.

Additional information and the most up-to-date numbers regarding products and services can be found at Jordan's Principle.

Through Budget 2021 funding, Indigenous Services Canada has supported over 100 Indigenous partners and health organizations to implement over 150 Indigenous-led initiatives nationally. These initiatives address anti-Indigenous racism in health systems and improve access to high quality and culturally safe health services for Indigenous Peoples across all provinces and territories, and in urban settings.

The Government of Canada also committed $2 million to the Conseil des Atikamekw de Manawan and the Conseil de la Nation Atikamekw to advance their advocacy for the implementation of Joyce's Principle. Joyce's Principle aims to guarantee to all Indigenous Peoples the right of equitable access, without any discrimination, to all social and health services, as well as the right to enjoy the best possible health. Funding provided by the Government of Canada supported the creation of the Joyce's Principle Office, which carries out projects to improve equitable access to health and social services for Indigenous Peoples.

In February 2022, Indigenous Services Canada announced a partnership with the Federation of Sovereign Indigenous Nations in Saskatchewan to establish the first ever First Nations Health Ombudsperson's Office. The First Nations Health Ombudsperson Office held its grand opening on October 3, 2023. The initiative ensures First Nations have a point of contact where they feel safe to be able to report incidents of discrimination when accessing health care service in the province. The office also assists in determining options to resolve conflicts or concerns for overall system change improvements.

Since the announcement of the new Indigenous Health Equity Fund in early 2023, Indigenous Services Canada has worked extensively with national and regional Indigenous partners on the design and implementation of the program. The Government of Canada is providing $2 billion over 10 years (or $200 million annually), beginning in 2024 to 2025, to support distinctions-based, Indigenous-led approaches to increasing access to quality and culturally safe health care.

This includes distinctions-based funding:

• $190 million (or 95%) for First Nations, Inuit, and Métis partners
• $10 million (or 5%) for targeted initiatives: for Indigenous organizations to promote innovation and close gaps on targeted priorities, such as urban, women's health and 2SLGBTQI+. This program will provide a stable, long-term foundation for increasing Indigenous access to quality and culturally safe health services.

Next steps

The Health Transformation initiative is aiming to finalize Agreements-in-Principle with the Keewatinohk Inniniw Minoayawin Inc., Southern Chiefs Organization and Tajikeimɨk in the upcoming fiscal year. Partners are aiming for full transfer to occur within 3 to 4 years.

In light of recent feedback from partners on the distinctions-based Indigenous health legislation Key Elements document, the federal initiative to co-develop Indigenous Health Legislation has reached a critical juncture, which requires a review of options to determine the best course of action. ISC continues to receive and analyze feedback from partners and is reflecting on options that would provide more time and transparency to help the process move forward in a meaningful way, based on partners' readiness and ongoing engagement.

Over the coming months, ISC will continue to work with Indigenous partners on the implementation of the Indigenous Health Equity Fund and ongoing management of the program, including their reporting on progress.

Recent budget investments

To build on the progress made through the Budget 2021 investment to take action to foster health systems free from racism and discrimination where Indigenous Peoples are respected and safe, Budget 2024 proposes to provide $167.6 million over 5 years, starting in 2024 to 2025, to combat anti-Indigenous racism in health care to help ensure Indigenous Peoples are treated with the respect and safety they deserve. These investments will continue supporting patient advocates, health system navigators, midwives, and birth support workers, as well as initiatives to increase Indigenous representation in the health professions.

Budget 2024 also proposes to provide $630.2 million over 2 years, starting in 2024 to 2025, to support Indigenous people's access to mental health services, including through distinctions-based approaches to mental wellness. Separate to this investment, the 2022 Fall Economic Statement announced $225 million over 5 years, starting in 2022 to 2023 to support recruitment and retention of health professionals on reserve.

On February 7, 2023, the federal government announced new investments to improve health care for all Canadians, including Indigenous Peoples, and is working with provinces, territories, and Indigenous partners to help advance our shared health priorities. Bilateral agreements with provinces and territories will be supported by key principles, including a commitment to reconciliation with Indigenous Peoples and recognizing their right to fair and equal access to health services, free from racism and discrimination anywhere in Canada. This includes seamless service delivery across jurisdictions and meaningful engagement with Indigenous organizations and governments.

As part of the federal government's plan to strengthen Canada's health system, Budget 2023 reaffirmed the Government of Canada commitment to invest $2 billion over 10 years through a new Indigenous Health Equity Fund to address unique challenges Indigenous Peoples face when it comes to fair and equitable access to quality and culturally safe health care services.

Budget 2023 also introduced additional measures to maintain essential health services for Indigenous Peoples. Specifically, the Government of Canada provided $458.6 million in 2023 to 2024 to maintain supplementary health benefits coverage provided to eligible First Nation and Inuit through the Non-Insured Health Benefits Program and expanded coverage of Continuous Glucose Monitoring Systems as part of the Program's pharmacy benefit. The Government of Canada is also providing $16.2 million over 3 years, beginning in 2023 to 2024, for interventions to reduce rates of tuberculosis in Inuit communities. More recently, Budget 2024 proposes to provide $562.5 million in 2024 to 2025 to support medically necessary services through the Non-Insured Health Benefits Program, which supports a range of benefits for First Nations and Inuit people, including mental health services, medical travel, medications, and more.

PHAC has provided $200,000 to the First Nations Information Governance Centre (FNIGC) to support work until the end of 2025 on the development of a new report on mental wellness inequalities experienced by First Nations Peoples living on reserve and in northern communities.

In addition $27.5 million is being provided over 4 years (fiscal years 2023 to 2024 to 2026 to 2027) for First Nations, Inuit and Métis partners for health and human resources in data capacity. This funding is to support partners in hiring epidemiologists or data analysts and to continue building health data capacity and continue building distinctions-based data strategies.

The Government of Canada has also invested in Health Transformation projects through Budget 2018 ($71.1 million over 3 years) and Budget 2021 ($107.1 million over 3 years) to support health service transfer with partners in Saskatchewan, Manitoba, Ontario, Quebec and Nova Scotia. Budget 2024 proposes to provide $104.9 million over 5 years, starting in 2024 to 2025, for health transformation initiatives to support First Nations self-determination in the design and delivery of health services in their communities.

Recent progress

There are currently more than 150 Indigenous-led initiatives supported by Budget 2021 that respond to many of the recommendations from the national dialogues and other key reports. Many of these initiatives are aimed at closing the gaps in health outcomes between Indigenous and non-Indigenous communities, with a focus on services for Indigenous women, 2SLGBTQI+ people, people with disabilities and other marginalized groups who may experience intersecting discrimination.

To close the gap in health outcomes and to ensure availability of appropriate health services for Indigenous peoples funding was provided to urban Indigenous service delivery organizations, Indigenous health centres and Indigenous communities to hire new Indigenous Health System Navigators. These Health System Navigators support Indigenous patients in navigating the federal, provincial and territorial health system. Funding was also provided to Indigenous health service delivery organizations to hire Indigenous Patient Advocates to help Indigenous patients access provincial, territorial and professional regulatory processes, and work to resolve complaint issues within existing provincial and territorial ombudsperson or complaint resolution frameworks.

In February 2022, Indigenous Services Canada announced a partnership with the Federation of Sovereign Indigenous Nations in Saskatchewan to establish the first ever First Nations Health Ombudsperson's Office. The First Nations Health Ombudsperson Office held its grand opening on October 3, 2023. The initiative ensures First Nations have a point of contact where they feel safe to be able to report incidents of discrimination when accessing health care service in the province. The office also assists in determining options to resolve conflicts or concerns for overall system change improvements.

As of March 2024, 2900 Indigenous patients across the country have accessed Indigenous Health System Navigator services, assisting Indigenous patients with accessing and navigating health systems in a culturally safe manner. Further, Indigenous Patient Advocates have supported approximately 100 patients in accessing provincial and territorial complaints resolution processes. Initiatives like these are important steps to address gaps and immediate concerns identified by Indigenous partners during the national dialogues.

Since the announcement of the new Indigenous Health Equity Fund in early 2023, Indigenous Services Canada has worked extensively with national and regional Indigenous partners on the design and implementation of the program. The Government of Canada is providing $2 billion over 10 years (or $200 million annually), beginning in 2024 to 2025, to support distinctions-based, Indigenous-led approaches to increasing access to quality and culturally safe health care.

This includes distinctions-based funding for First Nations, Inuit, and Métis partners $190 million (or 95%) and funding for targeted initiatives $10 million (or 5%). Targeted initiatives funding for Indigenous organizations is aimed at promoting innovation and closing health gaps for targeted priority groups, such as urban, women and 2SLGBTQI+. This program will provide a stable, long-term foundation for increasing Indigenous access to quality and culturally safe health services.

Indigenous Services Canada has also worked with Health Canada to support a series of trilateral discussions with regional Indigenous leadership and their respective provincial and territorial governments, which have provided opportunities for all involved to discuss Indigenous health priorities and ways to address them.

Indigenous Services Canada continues to collaborate with Statistics Canada, the Public Health Agency of Canada and Indigenous organizations such as the First Nations Information Governance Centre (FNIGC) and Inuit Tapiriit Kanatami (ITK) on establishing health indicators that can identify gaps and be routinely reported. The First Nations Information Governance Centre has finalized a scan and review of health frameworks and indicators developed by Indigenous academics and organizations that forms the basis on which an informed decision can be made in the selection of Call to Action 19 indicators. A more refined list will be created from this scan and discussions with partners will continue in order to create a final list of First Nations specific indicators. It is anticipated that indicators currently existing in the Regional Health Survey and Qanuippitaa. National Inuit Health Survey will provide many of the outcome measures for Call to Action 19. Work also continues with ITK to refine and finalize an Inuit-specific indicator list. This work is essential to the identification of outcome measures that are inclusive and reflective of Indigenous perspectives. At the same time, the Pan-Canadian Health Inequalities Reporting initiative measures health inequalities between First Nations (on- and off-reserve), Inuit (within and outside Inuit Nunangat), Métis, and up to 13 additional sociodemographic groups. A health inequalities data tool was created using data from this joint initiative between the Public Health Agency of Canada, the Pan-Canadian Public Health Network, Statistics Canada and the Canadian Institute for Health Information.

The first major refresh of the health inequalities data tool was completed in 2022. The tool now includes inequalities results sorted by First Nations living off reserve, Inuit or Métis identity for 81 new and updated indicators of health outcomes and determinants of health. New indicators focus on priority public health areas such safe and stable housing, mental health, and access to care. Feedback on this update was sought through an ongoing partnership with FNIGC, MNC, ITK, AFN, the First Peoples Wellness Circle and other members of HIRI's Pan-Canadian Health Inequalities Working Group.

PHAC continues to work with FNIGC to improve our understanding of the drivers of health inequalities in Canada and how they have changed over time. To highlight the various approaches to mental health and wellness, including Indigenous perspectives, enhanced reports that include both qualitative and quantitative evidence are currently being developed.

Upcoming HIRI reporting will focus on the topic of social determinants of mental health inequalities in Canada. These can include, but are not limited to:

• socio-economic conditions
• stigma and discrimination
• access
• quality and use of services
• social isolation and community belonging

In addition to a narrative report, a data tool will be created with a focus on trends in mental health and wellness outcomes. These outcomes will be categorized by Indigenous identity where sample sizes allow and provide actionable insights at the program and policy levels.

PHAC has also partnered with ISC and FNIGC to support the development of complementary assessments that measure, monitor, and report on mental wellness inequalities experienced by First Nations Peoples living on reserve and in northern communities. This report is expected by 2025.

Health Transformation is currently supporting 6 Health Transformation tables who represent more than 150 First Nations across Canada and include:

• Keewatinohk Inniniw Minoayawin Inc. in Manitoba
• Southern Chiefs Organization in Manitoba
• Nishnawbe Aski Nation in Ontario
• La Commission de la santé et des services sociaux des Premières Nations du Québec et du Labrador
• Tajikeimɨk in Nova Scotia
• Battleford Agency Tribal Council in Saskatchewan

These partners are working to establish tripartite partnerships with the eventual goal of delivering health services to their communities that meet their health needs and priorities. These partners are also working with provinces and the federal government to collect data and information on the current state of health services and conditions in their communities so they develop approaches that directly address communities' priorities. For example, Tajikeimɨk has expanded their health surveillance functions through the Mi'kmaw Client Linkage Registry and plans to implement new indicators to inform health planning and surveillance.

Next steps

Planned activities for 2023 to 2024 include:

• continuing work with FNIGC on the mental health report
• expanding HIRI's data tool with new and updated data points
• continuing work to refine the list of indicators with First Nations, Métis and Inuit partners
• monitoring changes over time in health inequalities in Canada

These activities will help capture updated health indicators for First Nations (on- and off-reserve), Inuit (inside and outside Inuit Nunangat), and Métis (in rural and urban environments).

Work will continue to support tripartite partnerships through the Health Transformation process and to support on service transfer with Health Transformation partners. It is expected that 3 partners will be implementing full service transfer in 3 to 4 years.

Over the coming months, Indigenous Services Canada will continue to work with Indigenous partners on the implementation of the Indigenous Health Equity Fund and ongoing management of the program, including their reporting on progress.

COVID-19 pandemic response

The Government of Canada recognizes that First Nations, Inuit, Métis, regardless of where they live within Canada, experience a disproportionate burden of ill health, which is rooted in Canada's colonial policies and existing health and social services that fail to adequately meet needs. The Canadian health system is a complex patchwork of jurisdictions, policies, legislation, and relationships. Coordinated approaches to address the health needs of First Nations, Inuit, and Métis Peoples and health care delivery amongst all levels of government, including Indigenous governments, remain an ongoing challenge. Additionally, there are significant challenges that Indigenous peoples face when interacting with health systems, including anti-Indigenous racism, a lack of cultural safety and a lack of understanding and acceptance of Indigenous health and healing models.

Throughout the COVID-19 pandemic, the Indigenous Community Support Fund provided Indigenous leadership and organizations with the flexibility needed to design and implement community-based solutions to prevent, prepare and respond to the spread of COVID-19 within their communities.

As of March 31, 2023, $1.2 billion in direct allocations have been provided to First Nations, Inuit, and Métis communities, and $851 million in needs-based funding. In addition to the Indigenous Community Support Fund, the Government of Canada invested $1.67 billion in COVID-19 Public Health Funding since the start of the pandemic.

The urgency of addressing anti-Indigenous racism in the health systems also arose during the pandemic. The national dialogues on anti-Indigenous racism in health systems included organizations that represent First Nations, Métis, Inuit, in urban and non-urban contexts, in order to better understand not only common barriers that all Indigenous Peoples face but also distinct perspectives and lived experiences.

In response to the priorities identified at the national dialogues, the Addressing Anti-Indigenous Racism in Canada's Health Systems initiative at Indigenous Services Canada was designed to respond to the distinct health needs of First Nations, Métis, Inuit, Non-Status and urban Indigenous People. To achieve this, the program supports Indigenous led initiatives and provided flexible, distinctions-based, funding to urban Indigenous service delivery organizations such as through First Nation, Métis and Inuit focused health centers and organizations in urban areas. For example, funding was provided to the National Association of Friendship Centres, which is an urban-based Indigenous organization, and other Indigenous health centres who provide services for Indigenous Peoples living in urban areas.

The Government of Canada is committed to working in partnership to continue to advance the priorities expressed by Indigenous Peoples about their health and to improve access to high quality, culturally safe health services. In 2019, the Government of Canada made a commitment to support engagement with Indigenous Peoples to identify priorities and hear how distinctions-based Indigenous Health Legislation might help create the change necessary to address health gaps and inequities. The commitment extends to working with First Nations, Inuit, and Métis partners, as well as Indigenous partners with intersectional lenses, to co-develop potential legislative options that advance the priorities identified through engagement. The Minister of Indigenous Services publicly launched the engagement process on Indigenous health legislation on January 28, 2021, during the second national dialogue on anti-Indigenous racism in health care.

The engagement process wrapped up in fall 2022. The national summary report, What We Heard: Visions for Distinctions-based Indigenous Health Legislation includes input from Indigenous peoples living in urban and off-reserve areas, who highlighted the need for funding for capacity and infrastructure for urban health services.

Additionally, work continues on Jordan's Principle and the Inuit Child First Initiative. These initiatives ensure that First Nations and Inuit children have access to the products, services and supports they need, regardless of where they live in Canada. This includes First Nations children living on or off-reserve and Inuit children living inside and outside Inuit Nunangat. The Government of Canada works with organizations such as friendship centres to support urban populations. These initiatives can help with a wide range of health, social and educational needs.

Between April 1, 2019 and March 31, 2024, the Inuit Child First Initiative approved 204,433 products, services, and supports for Inuit children.

• 2019 to 2020: 4,279
• 2020 to 2021: 26,014
• 2021 to 2022: 31,711
• 2022 to 2023: 52,550
• 2023 to 2024: 92,879

Recent budget investments

To build on the progress made through the Budget 2021 investment to take action to foster health systems free from racism and discrimination where Indigenous Peoples are respected and safe, Budget 2024 proposes to provide $167.6 million over 5 years, starting in 2024 to 2025, to combat anti-Indigenous racism in health care to help ensure Indigenous Peoples are treated with the respect and safety they deserve. These investments will continue supporting patient advocates, health system navigators, midwives, and birth support workers, as well as initiatives to increase Indigenous representation in the health professions.

Budget 2022 provided $4 billion over 6 years, starting in 2021 to 2022, to ensure First Nations children continue to receive the support they need through Jordan's Principle. Budget 2023 provided an additional $171 million in 2022 to 2023 to ensure First Nations children continue to receive the support they need through Jordan's Principle. Budget 2024 proposes to provide $167.5 million over 2 years, starting in 2023 to 2024, to ensure Inuit children can access the health, social, and educational services they need. The government continues to work with Inuit partners to advance the long-term vision of the Inuit Child First Initiative so that Inuit children will continue to receive timely, high-quality services.

Budget 2023 also reaffirmed the Government of Canada commitment to invest $2 billion over 10 years through a new Indigenous Health Equity Fund to address unique challenges Indigenous Peoples face when it comes to fair and equitable access to quality and culturally safe health care services. Funding will be provided to First Nations, Inuit, and Métis on a distinctions basis.

Recent progress

Through the Addressing Anti-Indigenous Racism in Canada's Health Systems initiative, the Government of Canada has invested in approximately 120 projects that primarily benefit First Nations individuals and communities. These projects are currently working in the areas of sexual and reproductive health, forced and coerced sterilization of Indigenous women, maternal and child health, Indigenous midwifery, and wraparound services. Canada also funded the Métis National Council's Governing Members and the Manitoba Métis Federation to implement a dozen projects that benefit Métis citizens. Also, 3 health system navigators were hired by the Métis Nation-Saskatchewan to provide health system navigation support to approximately 10,000 Métis citizens. Further, Inuit partners have been funded to implement approximately 12 projects that primarily benefit Inuit and work to improve cultural safety, and increase access to Indigenous health system navigators across Nunavut, Inuvialuit Settlement Region and Nunavik. Additionally, funding for urban Indigenous service delivery organizations included the National Association of Friendship Centres, that was funded to hire health system navigators in 22 friendship centres across the country to assist urban Indigenous patients in navigating health systems.

Starting in fall 2022, Canada established distinctions-based working level groups with Indigenous partners, or co-development tables, to meet regularly and translate what was heard through engagement on distinctions-based Indigenous health legislation into proposed legislative options. In total, 14 separate co-development tables were established with First Nations, Inuit, and Métis partners, as well as Indigenous partners with intersectional lenses, between October 2022 and June 2023. Participation in the co-development tables offered another opportunity for partners to help identify potential federal legislative and policy measures that would support Indigenous-led and distinctions-based approaches to health. The co-development table for Indigenous partners with intersectional lenses included organizations that serve Indigenous peoples living in urban areas. One of the key themes discussed at the intersectional co-development table was health services for Indigenous peoples living away from home, off-reserve, or in urban areas, and the unique health challenges and needs of these populations.

Informed by the discussions and input from partners, ISC prepared a Key Legislative Elements document and shared it widely to all partners for review and feedback. The Key Legislative Elements document presents a high-level compilation of potential legislative and policy options that are being considered. A significant amount of feedback was received from First Nations, Inuit, and Métis partners, as well as Indigenous partners with intersectional lenses, on the Key Legislative Elements document during the month of September 2023. In just over 3 weeks, ISC facilitated 27 distinct dialogues with partners and received 39 separate written submissions in reaction to the Key Legislative Elements document.

Since the announcement of the Indigenous Health Equity Fund in early 2023, Indigenous Services Canada has worked extensively with national and regional Indigenous partners, including Inuit and Métis, on the design and implementation of the program. The Government of Canada is providing $2 billion over 10 years (or $200 million annually), beginning in 2024 to 2025, to support distinctions-based, Indigenous-led approaches to increasing access to quality and culturally safe health care. This includes distinctions-based funding: $190 million (or 95%) for First Nations, Inuit, and Métis partners and targeted initiatives: $10 million (or 5%) for Indigenous organizations to promote innovation and close gaps on targeted priorities, such as urban, women's health and 2SLGBTQI+. This program will provide a stable, long-term foundation for increasing Indigenous access to quality and culturally safe health services.

Indigenous Services Canada has also worked with Health Canada to support a series of trilateral discussions with regional Indigenous leadership, including Inuit and Métis partners, and their respective provincial and territorial governments, which have provided opportunities for all involved to discuss Indigenous health priorities and ways to address them.

Next steps

In light of recent feedback from partners on the distinctions-based Indigenous health legislation Key Elements document, the federal initiative to co-develop Indigenous Health Legislation has reached a critical juncture, which requires a review of options to determine the best course of action. ISC continues to receive and analyze feedback from partners and is now reflecting on options that would provide more time and transparency to help the process move forward in a meaningful way, based on partners' readiness and ongoing engagement. The Government of Canada continues to work in partnership with First Nations and Inuit organizations to co-develop long term policy options for Jordan's Principle and the Inuit Child First Initiative and engage with relevant stakeholders to seek their views regarding access to the services and supports to meet the needs of First Nations and Inuit children.

Over the coming months, Indigenous Services Canada will continue to work with Indigenous partners on the implementation of the Indigenous Health Equity Fund and ongoing management of the program, including their reporting on progress.

Recent budget investments

Through Budget 2019, the Government of Canada committed $47.5 million over 5 years to support the design and construction of Aqqusariaq (formerly known as the Nunavut Recovery Centre) and $9.7 million ongoing in support of treatment centre operations. To date, approximately $21.2 million has been provided to the Government of Nunavut to support the design and construction as per the contribution agreement signed and endorsed in late August of 2021.

Budget 2021 provided $597.6 million over 3 years which included the renewal of Trauma-Informed Health and Cultural Support Programs. It will support enhanced community-based supports and capacity and increased substance use treatment and prevention. Budget 2022 provided an additional $227.6 million over 2 years, starting in 2021 to 2022, to maintain expanded access to trauma-informed, culturally-appropriate, Indigenous-led services to improve mental wellness and further support distinctions-based mental health and wellness strategies. Most recently, Budget 2024 proposes to provide $630.2 million over 2 years, starting in 2024 to 2025, to support Indigenous Peoples' access to mental health services, including through distinctions-based approaches to mental wellness strategies.

In November 2022, Prime Minister Trudeau announced a $42.5 million investment over 6 years and $4.5 million ongoing to construct a new wellness centre in James Smith Cree Nation, refurbish the existing treatment centre, fund wraparound services and transitional supports. This investment will support healing, mental health, and well-being of community members impacted by a mass stabbing in September 2022.

In May 2021, Tk'emlúps te Secwépemc First Nation announced that ground-penetrating radar had detected remains of 215 children who died at the former Kamloops Indian Residential School. The confirmations of unmarked burials at residential schools has accelerated the need for cultural and emotional supports for survivors, family members, and those affected by the intergenerational trauma of residential schools. In March 2023, the Government of Canada announced that Tk'emlúps te Secwépemc First Nation would receive $12.5 million in federal funding, directed through the First Nations Health Authority, towards the construction of a healing centre for the community. The healing centre is intended to deliver traditional healing activities and equine therapy, bringing much needed traditional healing to members of the community.

Budget 2024 also proposes to provide $104.9 million over 5 years, starting in 2024 to 2025, for health transformation initiatives to support First Nations self-determination in the design and delivery of health services in their communities.

Recent progress

On October 2, 2020, Indigenous Services Canada signed a Memorandum of Understanding with the Government of Nunavut and Nunavut Tunngavik Incorporated that outlines roles, responsibilities and governance between the parties for both the construction period and ongoing operations of Aqqusariaq (post the federal 5 year capital funding commitment). The Government of Canada (through Indigenous Services Canada) continues to meet regularly with the Government of Nunavut and Nunavut Tunngavik Incorporated through the Aqqusariaq Working Group and the Nunavut Partnership Table on Health.

Indigenous Services Canada has worked collaboratively with the Lac La Ronge Indian Band in the development of their Woodland Wellness Centre that provides one-of-a-kind programming where medicine co-exists with traditional and land-based healing. The 24-bed facility had its grand opening in June 2022 and is providing Indigenous-led health and wellness services to Indigenous Peoples in Northern Saskatchewan.

Since 2018, Indigenous Services Canada has invested $6.5 million into the construction of a new healing center in Kuujjuaq, Nunavik. The official opening of the Isuarsivik Regional Recovery Center took place in September 2023, and the Minister of Indigenous Services was on site for the inauguration. The new Isuarsivik Regional Recovery Center provides culturally appropriate substance use treatment services, including services for families in the healing process to lessen the impact of substance use on couples, pregnant women, and families with children.

Next steps

The design and construction of Aqqusariaq is on schedule. Site preparation and preliminary construction began in the summer of 2023, and is expected to be completed in December 2025. Indigenous Services Canada is currently working with James Smith Cree Nation to initiate planning of the First Nation-led wellness centre and refurbished treatment centre that will enable the community to develop and design programs that best serve the needs of the community. The community-led design and implementation plan for these projects will help inform internal government processes required to access and deliver this important funding to the community.

The Health Transformation initiative is supporting partners with their preparations to assume responsibility over health services and supports, including treatment.

Recent budget investments

The Government of Canada is currently investing over $200 million per year to support Trauma-Informed Health and Cultural Support Programs. This includes funding provided in Budget 2021 and Budget 2022 to support the Indian Residential Schools Resolution Health Support Program, the Indian Day Schools Health Support Program, and the Missing and Murdered Indigenous Women and Girls Health Support Program, as well as support for urban and Métis priorities.

Budget 2024 proposes to provide $630.2 million over 2 years, starting in 2024 to 2025, to support Indigenous Peoples' access to mental health services, including through distinctions-based approaches to mental wellness strategies.

Building on the early successes of the Budget 2017 midwifery demonstration projects, Budget 2021 provided an additional $33.3 million to improve access to culturally safe services, with a focus on services for Indigenous women, 2SLGBTQI+ people, persons with disabilities and other marginalized groups who may experience intersecting forms of discrimination. This includes $26.5 million to expand Indigenous midwifery and doula services, intended to help bring birthing back to, or closer to, home, through increased access to a continuum of culturally safe prenatal, birthing and postpartum care.

Budget 2021 provided $126.7 million over 3 years to addressing anti-Indigenous racism in Canada's health systems. Within this investment, $37.8 million over 3 years was allocated to hire Indigenous health system navigators and patient advocates who provide Indigenous patients with navigation supports and recourse to safely access federal and provincial health systems, respectively. More recently, Budget 2024 proposes to provide $167.6 million over 5 years, starting in 2024 to 2025, to combat anti-Indigenous racism in health care to help ensure Indigenous Peoples are treated with the respect and safety they deserve. These investments will continue supporting patient advocates, health system navigators, midwives and birth support workers, as well as initiatives to increase Indigenous representation in the health professions.

The Health Transformation initiative was supported with investments from Budget 2018 and 2021, and Budget 2024 proposes to provide $104.9 million over 5 years, starting in 2024 to 2025, for health transformation initiatives to support First Nations self-determination in the design and delivery of health services in their communities.

Budget 2024 also proposes to provide $562.5 million in 2024 to 2025 to support medically necessary services through the Non-Insured Health Benefits program, which supports a range of benefits for First Nations and Inuit people, including mental health services, medical travel, medications and more.

Recent progress

Recognizing there is a shortage of Indigenous midwives and that culturally safe birthing services are predicated on a sufficient work force, Budget 2021 investments are supporting the development of new community-based First Nations midwifery education and training programs in several regions including Labrador, Ontario, Quebec, and Nova Scotia. In addition, Budget 2021 is supporting expansion of the existing Six Nations First Nations training program.

• Sturgeon Lake First Nation, one of the original Budget 2017 demonstration projects, celebrated its first community midwife assisted birth in decades this past spring and has received additional Budget 2021 investments for construction of a new standalone birthing centre in the community, expected to break ground in the spring of 2023.
• Inuit Land Claim organizations have begun projects, including the Ungava Tulattavik Health Center (UTHC) in Kuujjuaq, Nunavik, to recruit additional trainees for their Inuulitsivik Midwifery Education Program, and allow the students to work alongside the existing four person midwifery team on a 24/7 basis.
• New Métis-specific midwifery and doula projects are set to begin implementation, including expansion of a Métis Doula mentorship program to train and mentor additional cohorts of Métis birth workers, expansion of pre-natal care and supports to a mobile clinic service, which travels to rural Métis communities to provide a wide range of primary care services, and planning for service delivery models and education and training on a long term strategy for culturally safe midwifery services in northern Métis communities.
• Indigenous Services Canada has funded the development and implementation of a network of Indigenous birth support workers in Saskatchewan to increase the accessibility of culturally appropriate services during labor and delivery. These birth workers have access to credentialled training and provide one-on-one advocacy and support to First Nations families. They also coordinate a network of referrals connecting families with community-based services to maximize the potential for a safe return home.
• Meadow Lake Tribal Council has begun work toward a community-based midwifery. program and birth lodge in Canoe Lake. They have developed an Elders' committee and will be holding community consultation to plan the path forward. A candidate has been identified and has been accepted into a training program for traditional midwives and will also pursue a degree in midwifery. They intend to replicate this process in other member Nations based on available resources and community readiness.
• First Nations University of Canada has developed and is delivering a credentialled program in Indigenous birth support work. Training is available both in-person and online to maximize accessibility. Some of the courses may be used toward a degree in midwifery. Additional modules related to sexually transmitted and blood borne infections and end of life care will be ready for implementation in fall 2024.

Traditional healer services for mental health counselling for Non-Insured Health Benefits clients continue to be offered through projects by First Nations and Inuit partners that respect their unique cultural contexts. Resources and services are being delivered by community-based First Nations and Inuit recipient organizations. The recipient organizations have the flexibility to determine appropriate providers of traditional healing services in support of mental wellness, to compensate them in a manner that is culturally appropriate and to define the types of activities that traditional healers may undertake.

Keewatinohk Inniniw Minoayawin Inc., the Southern Chiefs' Organization and Tajikeimik are anticipating concluding Health Transformation Agreements in Principle, which will lay out the conditions and governance structure that will be in place when the transfer of responsibility for the delivery and design of federally funded health services and supports occur. All 3 partners have indicated that they would like to see these Agreements in Principle concluded within the next 3 to 6 months, and that they are working towards a full service transfer within the next 3 to 4 years.

Starting in fall 2022, Canada established distinctions-based working level groups with Indigenous partners, or co-development tables, to meet regularly and translate what was heard through engagement on distinctions-based Indigenous health legislation into proposed legislative options. In total, 14 separate co-development tables were established with First Nations, Inuit and Métis partners, as well as Indigenous partners with intersectional lenses, between October 2022 and June 2023. Participation in the co-development tables offered another opportunity for partners to help identify potential federal legislative and policy measures that would support Indigenous-led and distinctions-based approaches to health. The co-development tables offered an opportunity to discuss traditional health and healing practices, and how legislation might support traditional health.

Informed by the discussions and input from partners, ISC prepared a Key Legislative Elements document and shared it widely to all partners for review and feedback. The Key Legislative Elements document presents a high-level compilation of potential legislative and policy options that are being considered. A significant amount of feedback was received from First Nations, Inuit and Métis partners, as well as Indigenous partners with intersectional lenses, on the Key Legislative Elements document during the month of September 2023. In just over 3 weeks, ISC facilitated 27 distinct dialogues with partners and received 39 separate written submissions in reaction to the Key Legislative Elements document.

Next steps

In light of recent feedback from partners on the Key Elements document, the federal initiative to co-develop Indigenous health legislation has reached a critical juncture which requires a review of options to determine the best course of action. Indigenous Services Canada continues to receive and analyze feedback from partners and is now reflecting on options that would provide more time and transparency to help the process move forward in a meaningful way based on partners' readiness and ongoing engagement.

Indigenous Services Canada will continue to support Indigenous midwifery projects and work closely with partners, including the National Council of Indigenous Midwives and National Indigenous Women's Organizations, through the Advisory Committee on Indigenous Women's Wellbeing, to improve and sustain access to culturally safe reproductive health services.

Indigenous Services Canada will also continue to support access to health and cultural support services for eligible individuals through the Trauma-Informed Health and Cultural Support Programs.

Work will continue to support tripartite partnerships through the Health Transformation process and to support on service transfer with Health Transformation partners. It is expected that 3 partners will be implementing full service transfer in 3 to 4 years.

Recent budget investments

Budget 2021 provided $354 million over 5 years, beginning in 2021 to 2022, to increase the number of nurses and other medical professionals in remote and isolated First Nations communities. Budget 2021 also provided $126.7 million over 3 years, beginning in 2021 to 2022, to take action to foster health systems free from racism and discrimination where Indigenous Peoples are respected and safe. This funding supports patient advocates, health system navigators, development of Indigenous licensed practical nurses, midwives and dental therapists, and cultural safety training for medical professionals.

More recently, Budget 2024 proposes to provide $167.6 million over 5 years, starting in 2024 to 2025, to combat anti-Indigenous racism in health care to help ensure Indigenous Peoples are treated with the respect and safety they deserve. These investments will continue supporting patient advocates, health system navigators, midwives and birth support workers, as well as initiatives to increase Indigenous representation in the health professions.

Indigenous Services Canada provided of $203,640 to the Canadian Association of Schools of Nursing to develop and launch an annual survey. The survey monitors progress, among Canadian schools of nursing, on the number of self-identified Indigenous (First Nations, Inuit, and Métis) nursing faculty employed in Canada and on the enrollment of self-identified Indigenous nursing students.

Through the 2022 Fall Economic Statement, the Government of Canada provided $250 million over 5 years to further support the recruitment and retention of health professionals on reserve. Finally, through Budget 2023, the Government of Canada reaffirmed plans to invest $2 billion over 10 years through the new Indigenous Health Equity Fund, to address unique challenges Indigenous Peoples face when it comes to fair and equitable access to quality and culturally safe health care services. Funding will be provided to First Nations, Inuit, and Métis on a distinctions basis and support Indigenous health priorities.

Budget 2024 also proposes to provide $390.4 million over 4 years, starting in 2024 to 2025, to build or renovate health facilities, including to support the Virtual Health Hub led by the Saskatchewan Indian Institute of Technologies of Whitecap Dakota First Nation, and the University of Saskatchewan. This funding will also improve the safety of primary care workers in remote and isolated on reserve First Nations communities.

Recent progress

Starting in fall 2022, Canada established distinctions-based working level groups with Indigenous partners, or co-development tables, to meet regularly and translate what was heard through engagement on distinctions-based Indigenous health legislation into proposed legislative options. In total, 14 separate co-development tables were established with First Nations, Inuit, and Métis partners, as well as Indigenous partners with intersectional lenses, between October 2022 and June 2023. Participation in the co-development tables offered another opportunity for partners to help identify potential federal legislative and policy measures that would support Indigenous-led and distinctions-based approaches to health. During co-development discussions, cultural competency for health care professionals and increasing Indigenous health human resources in health care were identified as priority areas by First Nations, Inuit and Métis partners, as well as Indigenous partners with intersectional lenses.

Informed by the discussions and input from partners, Indigenous Services Canada prepared a Key Legislative Elements document and shared it widely to all partners for review and feedback. The Key Legislative Elements document presents a high-level compilation of potential legislative and policy options that are being considered. A significant amount of feedback was received from partners on the Key Legislative Elements document during the month of September 2023. In just over 3 weeks, Indigenous Services Canada facilitated 27 distinct dialogues with partners and received 39 separate written submissions in reaction to the Key Legislative Elements document.

In addition to the cultural competency training requirement of all ISC staff, in 2023, a cultural competency training requirement was added to all nursing and paramedic agency contracts, requiring a minimum of 15 hours of culture competency training per year by any contractor providing services on behalf of ISC.

The 2023 Nursing Workforce Survey included an analysis of ISC employed nurses who self-identify as Indigenous to better understand the barriers and facilitators to retention of this subset of nurses in remote and isolated Indigenous communities.

With respect to primary care, Indigenous Services Canada is supporting a proposal from the University of Saskatchewan, in collaboration with Saskatchewan Polytechnic and the Northern Inter-Tribal Health Authority, for the establishment of an accredited dental therapy program. The proposed ladder program (which can advance students from dental aide to dental assistant to dental therapist) will focus on Indigenous student recruitment and enrolment. The program will also support virtual learning and will partner with northern campuses for learning close to home (such as Northern College). One of the main goals of the proposed dental therapy program is to have Indigenous graduates return to work in their communities.

Through the Addressing Anti-Indigenous Racism in Health Systems initiative, Indigenous Services Canada funded the development and implementation of a network of Indigenous birth support workers in Saskatchewan, to increase the accessibility of culturally appropriate services during labor and delivery. Also funded through this initiative was the First Nations University of Canada, who is delivering a credentialed program in Indigenous birth support work. This training is available both in-person and online to maximize accessibility, and some of the courses may be used to transition into other health careers.

Indigenous Services Canada also provides funding to Indigenous health organizations and Indigenous communities to build capacity and support the development of transformative measures that help eliminate anti-Indigenous racism in health systems:

• Indigenous Physicians Association of Canada continues to work as a national leader on addressing anti-Indigenous racism in health systems specifically in medical education. The association will also be creating and implementing a framework for accreditation changes needed to reduce anti-Indigenous racism in medical education.
• Indigenous Dental Association of Canada provides leadership in increasing awareness of anti-Indigenous racism in oral health care. The association is also supported to continue to provide expertise to the federal government on anti-racism in oral health care.
• Indigenous Pharmacy Professionals of Canada assists with the recruitment and retention of Indigenous students in pharmacy assistant, pharmacy technician, and PharmD programs across Canada. They also strive to provide leadership in the continuing professional development of all pharmacy professionals, curricular and accreditation guidance, cultural safety education, and scholarships.
• To date, 94 Indigenous health system navigators and 20 Indigenous patients advocates have been hired across Indigenous communities. These roles help to support and increase Indigenous representation in health care spaces while ensuring the provision of culturally safe care.

The Government of Canada is providing $2 billion over 10 years (or $200 million annually), beginning in 2024 to 2025, to support distinctions-based, Indigenous-led approaches to increasing access to quality and culturally safe health care. This includes Distinctions-Based Funding pf $190 million (or 95%) for First Nations, Inuit and Métis partners. and targeted initiatives of $10 million (or 5%) for Indigenous organizations to promote innovation and close gaps on targeted priorities, such as urban, women's health and 2SLGBTQI+. This program will provide a stable, long-term foundation for increasing Indigenous access to quality and culturally safe health services, which may include health human resources.

Next steps

In light of recent feedback from partners on the Key Elements document, the federal initiative to co-develop Indigenous health legislation has reached a critical juncture, which requires a review of options to determine the best course of action. ISC continues to receive and analyze feedback from partners and is now reflecting on options that would provide more time and transparency to help the process move forward in a meaningful way, based on partners' readiness and ongoing engagement. Indigenous Services Canada is supporting the Saskatchewan Indian Institute of Technology to expand the first dedicated Indigenous Practical Nursing program in Canada, which is rooted in Indigenous worldviews and ways of knowing. Funding provided will be to increase the number of Indigenous Practical Nurses through increasing the overall number of available seats and to enhance the reach of the existing program to rural and remote areas of Saskatchewan through mobile training laboratories and outreach programming. Indigenous Services Canada is also a supporting partner in the establishment of the Saskatchewan Indian Institute of Technology's Virtual Health Hub. The Virtual Health Hub aims to improve health outcomes for Indigenous peoples living in rural, remote, and northern communities by utilizing technology to increase access to essential health care services and programs offered throughout Saskatchewan.

Indigenous Services Canada is supporting First Nations University of Canada in the development enhancement and delivery of certificate level programs for Traditional Birth Support Workers, including 2 certificate extension programs.

Indigenous Services Canada will also work with partners to develop a fulsome Indigenous Health Human Resources Framework to support the development, retention and recruitment of Indigenous health human resources across Canada.

Over the coming months, Indigenous Services Canada will continue to work with Indigenous partners on the implementation of the Indigenous Health Equity Fund and ongoing management of the program, including their reporting on progress, which may encompass monitoring on the types of activities being funded, such as health human resources.