Canada-Manitoba Agreement to Work Together to Improve Health Care for Canadians (2023-24 to 2025-26)

Tables of contents

• Funding agreement
• Annex 1 – Common statement of principles on shared health priorities
• Annex 2 – Shared pan-Canadian interoperability roadmap
• Annex 3 – Headline common indicators
• Annex 4 – Action plan

Funding agreement

(the "Agreement")

BETWEEN:

HIS MAJESTY THE KING IN RIGHT OF CANADA (hereinafter referred to as "Canada" or "Government of Canada") as represented by the Minister of Health and the Minister of Mental Health and Addictions and Associate Minister of Health (herein referred to as "the federal Ministers")

- and -

HIS MAJESTY THE KING IN RIGHT OF THE PROVINCE OF MANITOBA (hereinafter referred to as "Manitoba" or "Government of Manitoba") as represented by the Minister of Health, Seniors and Long-Term Care and the Minister of Housing, Addictions and Homelessness  (herein referred to as "the provincial Ministers")

REFERRED to collectively as the "Parties", and individually as a "Party"

PREAMBLE

WHEREAS, on February 24, 2023, Canada and Manitoba announced an overarching agreement in principle on Working Together to Improve Health Care for Canadians, supported by almost $200 billion over ten years in federal funding, including $46.2 billion in new funding to provinces and territories;

WHEREAS,Canada has also announced a 5 per cent Canada Health Transfer (CHT) guarantee for the next five years, starting in 2023-24, which will be provided through annual top-up payments as required. This is projected to provide approximately an additional $17 billion over 10 years in new support. The last top-up payment will be rolled into the CHT base at the end of the five years to ensure a permanent funding increase, providing certainty and sustainability to provinces and territories;

WHEREAS, Working Together to Improve Health Care for Canadians includes a federal commitment of $25 billion in bilateral funding to provinces and territories over ten years focused on four shared health priorities:

• expanding access to family health services, including in rural and remote areas;
• supporting our health workers and reducing backlogs;
• improving access to quality mental health and substance use services; and
• modernizing health systems with health data and digital tools.

WHEREAS, in the area of mental health, substance use, and addictions services, Working Together to Improve Health Care for Canadians also includes a commitment by Canada and Manitoba to continue to work to support collaboration on the Common Statement of Principles on Shared Health Priorities (hereinafter referred to as the "Common Statement", attached hereto as Annex 1), supported by the federal Budget 2017 investment of $5 billion over ten years;

WHEREAS, Manitoba has the primary responsibility for delivering health care services to its residents and supports diversity, equity, and the needs of underserved and/or disadvantaged populations, including, but not limited to First Nations, Inuit and Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+; WHEREAS, Canada authorized the federal Ministers to enter into agreements with the provinces and territories, for the purpose of identifying activities that provinces and territories will undertake in respect of the four shared health priorities, and for funding in this Agreement associated with the federal investment for mental health, substance use, and addictions services consistent with the Common Statement (and menu of actions outlined in Annex 1);
WHEREAS, the Executive Government Organization Act authorizes the provincial Ministers to enter into agreements with the Government of Canada under which Canada undertakes to provide funding toward costs incurred by the Government of Manitoba associated with the federal investment for four shared health priorities, and mental health, substance use and addictions services consistent with the Common Statement; and
NOW THEREFORE, this Agreement sets out the terms between Canada and Manitoba as follows:

1.0 Key Principles and Collaboration

The key principles and commitment to collaboration agreed to in Working Together to Improve Health Care for Canadians are outlined below.

1.1. Canada and Manitoba acknowledge that this Agreement will mutually respect each government's jurisdiction, and be underpinned by key principles, including:

• A shared responsibility to uphold the Canada Health Act that strengthens  our public health care system;
• Principles agreed to in the Common Statement (outlined in Annex 1);
• Reconciliation with Indigenous Peoples, recognizing their right to fair and equal access to quality and culturally safe health services free from racism and discrimination anywhere in Canada, including through seamless service delivery across jurisdictions and meaningful engagement and work with Indigenous organizations and governments; and
• Equity of access for under-served groups and individuals, including those in official language minority communities.

1.2 Canada and Manitoba acknowledge the importance of supporting health data infrastructure, data collection and public reporting, and will work together to improve the collection, sharing and use of de-identified health information, respecting federal/provincial/territorial privacy legislation, to improve transparency on results and to help manage public health emergencies, and to ensure Canadians can access their own health information and benefit from it being shared between health workers across health settings. This includes:

• collecting and securely sharing high-quality, comparable information needed to improve services to Canadians, including disaggregated data on key common health indicators with the Canadian Institute for Health Information (CIHI);
• adopting common interoperability standards (both technical exchange and content of data), including the Shared pan-Canadian Interoperability Roadmap (outlined in Annex 2), to improve Canadians' access to their health information in a usable digital format and support the exchange and analysis of health data within and across Canada's health systems in a way that protects Canadians' privacy and ensures the ethical use of data to improve the health and lives of people;
• work to align provincial and territorial policies and legislative frameworks where necessary and appropriate to support secure patient access to health information, and stewardship of health information to support the public good, including improving care quality, patient safety, privacy protection, system governance and oversight, planning and research;
• promoting health information as a public good by working with federal-provincial-territorial Ministers of Health to review and confirm overarching principles, which would affirm Canadians' ability to access their health information and have it follow them across all points of care. The existing  Health Data Charter, as outlined in the Pan-Canadian Health Data Strategy, would serve as the starting point for the discussion of these principles; and
• collecting and sharing available public health data (e.g., vaccination data, testing data) with the Public Health Agency of Canada to support Canada's preparedness and response to public health events, building on commitments made as part of the Safe Restart Agreements.

1.3 Canada and Manitoba acknowledge they will work with other provinces and territories to streamline foreign credential recognition for internationally-educated health professionals, and to advance labour mobility, starting with multi-jurisdictional recognition of health professional licences.

1.4 Canada and Manitoba acknowledge a mutual intent to engage in a two-phased formal review process:

1. Phase 1: This review will be done in 2026 by a joint committee of Federal, Provincial, and Territorial health and finance officials to assess results and determine next steps for bilateral agreements related to improvements to home and community care, mental health, substance use, and addiction services associated with the Common Statement and long-term care; and
2. Phase 2: A formal five-year review of the healthcare plan outlined on February 7, 2023, recognizing the importance of long-term sustainability for provincial-territorial health systems. This review would consist of an assessment of both the bilateral agreements (herein) and the CHT investments (not included as part of this bilateral agreement). The review will be done by a joint committee of Federal, Provincial, and Territorial health and finance officials, commencing by March 31, 2027, and concluded by December 31, 2027, to consider results achieved thus far in the four shared health priority areas and will include:
   1. an assessment of progress-to-date on public reporting to Canadians using the common indicators;
   2. sharing of de-identified health information, and other health data commitments; and
   3. current and forward-looking Federal, Provincial, and Territorial investments to support this plan.

2.0 Objectives

2.1 Canada and Manitoba agree that, with financial support from Canada, Manitoba will continue to build and enhance health care systems towards achieving some or all of the objectives of:

• timely access to high-quality family health services, including in rural and remote areas;
• a sustainable, efficient and resilient health workforce that provides Canadians timely access to high-quality, effective, and safe health services;
• access to timely, equitable, and quality mental health, substance use, and addictions services to support Canadians' well-being; and
• access to a patient's own electronic health information that is shared between the health professionals they consult to improve safety and quality of care, and which informs Canadians on how the system is working.

2.2 Canada and Manitoba agree that, with Budget 2017 financial support from Canada outlined in 5.2.2, Manitoba will continue to work to improve access to mental health, substance use, and addictions services consistent with the Common Statement (and menu of actions outlined in Annex 1).

3.0 Action Plan

3.1 Manitoba set out in their Action Plan (attached as Annex 4) how the federal investment under this Agreement will be used, as well as details on targets and timeframes based on common headline indicators in priority areas where federal funds will be invested, as well as jurisdiction-specific indicators, for each of the initiatives.

3.2 Manitoba will invest federal funding as part of the 2017 commitment for mental health, substance use, and addictions services provided through this Agreement in alignment with the menu of actions listed in the Common Statement.

3.3 Manitoba will invest federal funding in some or all of the four shared health priority areas, without displacing existing planned spending in those areas.

3.4 In developing initiatives under this Agreement, Manitoba agrees to implement measures that also respond to the needs of underserved and/or disadvantaged populations, including, but not limited to First Nations, Inuit and Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+.

3.5 Manitoba's approach to achieving objectives is set out in their three-year Action Plan (2023-24 to 2025-26), as set out in Annex 4.

4.0 Term of Agreement

4.1 This Agreement comes into effect upon the date of the last signature of the Parties and will remain in effect until March 31, 2026 ("the Term"), unless terminated in accordance with section 11 of this Agreement. Funding provided under this Agreement will cover the period April 1, 2023 to March 31, 2026.

4.2 Renewal of Bilateral Agreements

4.2.1 Upon signing renewed bilateral agreements, Manitoba will have access to the remainder of its share of the federal funding, subject to appropriation by Parliament, for:

• 2026-27, the allocation based on the federal commitment in Budget 2017 of $5 billion over ten years for mental health, substance use and addiction services; and
• 2026-27 to 2032-33, the allocation based on the federal commitment in Budget 2023 of $25 billion over ten years to support the Working Together to Improve Health Care for Canadians plan.

5.0 Financial Provisions

5.1 The funding provided under this Agreement is in addition to and not in lieu of those that Canada currently provides under the CHT to support delivering health care services within the province.

5.2 Allocation to Manitoba

5.2.1 In this Agreement, "Fiscal Year" means the period commencing on April 1 of any calendar year and terminating on March 31 of the immediately following calendar year.

5.2.2 Canada has designated the following maximum amounts to be transferred in total to all provinces and territories under this initiative based on the allocation method outlined in subsection 5.2.3 for the Term of this Agreement.

Working Together to Improve Health Care for Canadians

1. $2.5 billion for the Fiscal Year beginning on April 1, 2023
2. $2.5 billion for the Fiscal Year beginning on April 1, 2024
3. $2.5 billion for the Fiscal Year beginning on April 1, 2025

Budget 2017 Mental Health, Substance Use, and Addictions Services

1. $600 million for the Fiscal Year beginning on April 1, 2023
2. $600 million for the Fiscal Year beginning on April 1, 2024
3. $600 million for the Fiscal Year beginning on April 1, 2025

5.2.3 Allocation Method

1. For the funding associated with Working Together to Improve Health Care for Canadians, annual funding will be allocated to provinces and territories on base ($5,000,000 if population is less than 100,000; $20,000,000 if population is between 100,000 and 500,000; and $50,000,000 if population is greater than 500,000) plus per capita basis. The final total amount to be paid to each jurisdiction will be calculated using the following formula: B + (F - ((N * 5,000,000) + (O * 20,000,000) + (S * 50,000,000)) x (K / L), where:

   B is the base amount allocated to each province or territory based on population ($5,000,000 if population is less than 100,000; $20,000,000 if population is between 100,000 and 500,000; and $50,000,000 if population is greater than 500,000), as determined using annual population estimates on July 1st from Statistics Canada;

   F is the total annual funding amount available outlined under this program;

   N is the number of provinces and territories with a population less than 100,000, as determined using annual population estimates on July 1st from Statistics Canada;

   O is the number of provinces and territories with a population between 100,000 and 500,000, as determined using annual population estimates on July 1st from Statistics Canada;

   S is the number of provinces and territories with a population greater than 500,000, as determined using annual population estimates on July 1st from Statistics Canada;

   K is the total population of Manitoba, as determined using annual population estimates on July 1st from Statistics Canada; and

   L is the total population of Canada, as determined using annual population estimates on July 1st from Statistics Canada.

1. For funds associated with Budget 2017 Mental Health, Substance Use, and Addictions Services, annual funding will be allocated to provinces and territories on a per capita basis. The per capita funding for each Fiscal Year, is calculated using the following formula: F x K/L, where:

   F is the annual total funding amount available under this program;

   K is the total population of Manitoba, as determined using the annual population estimates on July 1st from Statistics Canada; and

   L is the total population of Canada, as determined using the annual population estimates on July 1st from Statistics Canada.

5.3 Payment

5.3.1 Funding provided by Canada will be paid in semi-annual installments as follows:

1. In 2023-2024, the first installment will be paid within approximately 30 business days of execution of this Agreement by the Parties. The second installment will be paid on or about November 15.
2. Starting in 2024-2025, the first installment will be paid on or about April 15 of each Fiscal Year and the second installment will be paid on or about November 15 of each Fiscal Year.
3. The first installment will be equal to 50% of the notional amount set out in section 5.2.4 as adjusted by section 5.2.3.
4. The second installment will be equal to the balance of funding provided by Canada for the Fiscal Year as determined under sections 5.2.3 and 5.2.4.
5. Canada will notify Manitoba prior to the first payment of each Fiscal Year, of their notional amount. The notional amount will be based on the Statistics Canada quarterly preliminary population estimates on July 1 of the preceding Fiscal Year. Prior to the second payment, Canada will notify Manitoba of the amount of the second installment as determined under sections 5.2.3 and 5.2.4.
6. Canada shall withhold payments if Manitoba has failed to provide reporting in accordance with 7.1.
7. Canada shall withhold the second payment in 2023-24 if Manitoba has failed to satisfy all reporting requirements associated with the preceding Canada – Manitoba Home and Community Care and Mental Health and Addictions Services Funding Agreement 2022-23, specifically to:
   1. continue to participate in a Federal-Provincial-Territorial process to improve reporting on and provide data to CIHI for the 6 common indicators to measure pan-Canadian progress on improving access to mental health, substance use, and addictions services; and
   2. submit an annual financial statement, with attestation from the Manitoba Health Financial Officer, of funding received the preceding Fiscal Year from Canada for mental health and addiction services under the Canada – Manitoba Home and Community Care and Mental Health and Addictions Services Funding Agreement 2022-23 compared against the Expenditure Plan, and noting any variances, between actual expenditures and the Expenditure Plan.
8. The sum of both installments constitutes a final payment and is not subject to any further payment once the second installment has been paid.
9. Payment of Canada's funding for this Agreement is subject to an annual appropriation by the Parliament of Canada for this purpose.

5.4 Retaining Funds

5.4.1 For Fiscal Years 2023-24 through 2024-25, upon request, Manitoba may retain and carry forward to the next Fiscal Year up to 10 percent of funding that is in excess of the amount of the eligible costs actually incurred in a Fiscal Year and use the amount carried forward for expenditures on eligible areas of investment. Any request to retain and carry forward an amount exceeding 10 percent will be subject to discussion and mutual agreement in writing by their designated officials, at the Assistant Deputy Minister level (herein referred to as "Designated Officials"), and is subject to monitoring and reporting to Canada on the management and spending of the funds carried forward on a quarterly basis.

5.4.2 Any amount carried forward from one Fiscal Year to the next under this subsection is supplementary to the maximum amount payable to Manitoba under subsection 5.2.4 of this Agreement in the next Fiscal Year.

5.4.3 Upon request, Manitoba may retain and carry forward up to 10 percent of funding provided in the last Fiscal Year of this Agreement for eligible areas of investment, to be noted in the new agreement and subject to the terms and conditions of that new agreement. The new Action Plan will provide details on how any retained funds carried forward will be expended. Any request by Manitoba to retain and carry forward an amount exceeding 10 percent will be subject to discussion and mutual agreement in writing by their Designated Officials, and is subject to monitoring and reporting to Canada on the management and spending of the funds carried forward on a quarterly basis.

5.5 Repayment of overpayment

5.5.1. In the event payments made exceed the amount to which Manitoba is entitled under this Agreement, the amount of the excess is a debt due to Canada and, unless otherwise agreed to in writing by the Parties, Manitoba shall repay the amount within sixty (60) calendar days of written notice from Canada.

5.6 Use of Funds

5.6.1. The Parties agree that funds provided under this Agreement will only be used by Manitoba in accordance with the initiatives outlined in Annex 4.

5.7 Eligible Expenditures

5.7.1. Eligible expenditures under this Agreement are the following:

• data development and collection to support reporting;
• information technology and health information infrastructure;
• capital and operating funding;
• salaries and benefits;
• training, professional development; and
• information and communications material related to programs.

6.0 Performance Measurement

6.1 Manitoba agrees to designate an official or official(s), for the duration of this Agreement to participate in a CIHI led Federal-Provincial-Territorial indicator process to:

1. Refine the eight common headline indicators (outlined in Annex 3);
2. Work to identify additional common indicators that are mutually agreed upon, including indicators focused on the health of Indigenous populations with acknowledgement of the role for Indigenous partners in this work;
3. Improve reporting on common indicators to measure pan-Canadian progress on improving access to mental health, substance use, and addictions services, associated with the commitment in the Common Statement; and
4. Share available disaggregated data with CIHI and work with CIHI to improve availability of disaggregated data for existing and new common indicators to enable reporting on progress for underserved and/or disadvantaged populations including, but not limited to, Indigenous peoples, First Nations, Inuit, Métis, official language minority communities, rural and remote communities, children, racialized communities (including Black Canadians), and LGBTIQA2S+. 

7.0 Reporting to Canadians

7.1 Funding conditions and reporting

7.1.1 By no later than October 1, in each fiscal year, with respect of the previous Fiscal Year, Manitoba agrees to:

1. Provide data and information annually to CIHI related to the new headline indicators, additional common indicators, and the mental health, substance use, and addictions services indicators identified as part of commitment made in the Common Statement.
2. Beginning in Fiscal Year 2024-25, report annually and publicly in an integrated manner to residents of Manitoba on progress made on targets outlined in Annex 4 (Action Plan) for headline indicators in the priority area(s) where federal funds are to be invested, and on jurisdiction-specific indicators for each of the initiatives tailored to their jurisdiction's needs and circumstances.
3. Beginning in Fiscal Year 2024-25, provide to Canada an annual financial statement, with attestation from the Manitoba Health Financial Officer, of funding received the preceding Fiscal Year from Canada under this Agreement or the Previous Agreement compared against the Action Plan, and noting any variances, between actual expenditures and the Action Plan:
   1. The revenue section of the statement shall show the amount received from Canada under this Agreement during the Fiscal Year;
   2. The total amount of funding used for each of the shared health priority areas that are supported by the federal funds;
   3. If applicable, the amount of any funding carried forward under section 5.4; and
   4. If applicable, the amount of overpayment that is to be repaid to Canada under section 5.5.

7.1.2 Manitoba will provide quarterly reporting to Canada on the management and spending of the funds retained to the next Fiscal Year.

7.2 Audit

7.2.1 Manitoba will ensure that expenditure information presented in the annual financial statement is, in accordance with Manitoba's standard accounting practices, complete and accurate.

7.3 Evaluation

7.3.1 Responsibility for evaluation of programs rests with Manitoba in accordance with its own evaluation policies and practices.

8.0 Communications

8.1 The Parties agree on the importance of communicating with citizens about the objectives of this Agreement in an open, transparent, effective and proactive manner through appropriate public information activities.

8.2 Each Party will receive the appropriate credit and visibility when investments financed through funds granted under this Agreement are announced to the public.

8.3 In the spirit of transparency and open government, Canada will make this Agreement, including any amendments, publicly available on a Government of Canada website.

8.4 Manitoba will make publicly available, clearly identified on a Government of Manitoba website, this Agreement, including any amendments.

8.5 Canada, with prior notice to Manitoba, may incorporate all or any part of the data and information in 7.1, or any part of evaluation and audit reports made public by Manitoba into any report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.

8.6 Canada reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement and this Agreement. Canada agrees to give Manitoba 10 days advance notice and advance copies of public communications related to the Common Statement, this Agreement, and results of the investments of this Agreement.

8.7 Manitoba reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement and this Agreement. Manitoba agrees to give Canada 10 days advance notice and advance copies of public communications related to the Common Statement, this Agreement, and results of the investments of this Agreement.

8.8 Canada and Manitoba agree to participate in a joint announcement upon signing of this Agreement.

8.9 Canada and Manitoba agree to work together to identify mutually agreeable opportunities for joint announcements relating to programs funded under this Agreement.

9.0 Dispute Resolution

9.1 The Parties are committed to working together and avoiding disputes through government-to-government information exchange, advance notice, early consultation, and discussion, clarification, and resolution of issues, as they arise.

9.2 If at any time a Party is of the opinion that the other Party has failed to comply with any of its obligations or undertakings under this Agreement or is in breach of any term or condition of the Agreement, that Party may notify the other Party in writing of the failure or breach. Upon such notice, the Parties will endeavour to resolve the issue in dispute bilaterally through their Designated Officials.

9.3 If a dispute cannot be resolved by Designated Officials, then the dispute will be referred to the Deputy Ministers of Canada and Manitoba responsible for health, and if it cannot be resolved by them, then the federal Minister(s) and the provincial Minister(s) shall endeavour to resolve the dispute.

10.0 Amendments to the Agreement

10.1 The main text of this Agreement may be amended at any time by mutual consent of the Parties. Any amendments shall be in writing and signed, in the case of Canada, by the federal Minister(s), and in the case of Manitoba, by the provincial Minister(s).

10.2 Annex 4 may be amended at any time by mutual consent of the Parties. Any amendments to Annex 4 shall be in writing and signed by each Party's Designated Official.

11.0 Termination

11.1 Either Party may terminate this Agreement at any time if the terms are not respected by giving at least 6 months written notice of intention to terminate.

11.2 As of the effective date of termination of this Agreement, Canada shall have no obligation to make any further payments.

11.3 Sections 1.0, and 8.0 of this Agreement survive for the period of the 10-year Working Together to Improve Health Care for Canadians plan.

11.4 Sections 5.4 and 7.0 of this Agreement survive the termination or expiration of this Agreement until reporting obligations are completed.

12.0 Notice

12.1 Any notice, information, or document provided for under this Agreement will be effectively given if delivered or sent by letter, email, postage or other charges prepaid. Any communication that is delivered will be deemed to have been received in delivery; and, except in periods of postal disruption, any communication mailed by post will be deemed to have been received eight calendar days after being mailed.

The address of the Designated Official for Canada shall be:

Assistant Deputy Minister, Strategic Policy Branch

Health Canada
70 Colombine Driveway
Brooke Claxton Building
Ottawa, Ontario
K1A 0K9

Email: jocelyne.voisin@hc-sc.gc.ca

The address of the Designated Official for Manitoba shall be:

Associate Deputy Minister - Health, Seniors and Long-Term Care

Manitoba Health, Seniors and Long-Term Care
300 Carlton Street
Winnipeg, Manitoba
Email: Suzanne.Gervais@gov.mb.ca

Assistant Deputy Minister - Housing, Addictions and Homelessness

Manitoba Housing, Addictions and Homelessness
362 Donald Street
Winnipeg, Manitoba
Email: Keyur.Pathak@gov.mb.ca

13.0 General

13.1 This Agreement, including Annexes, comprises the entire Agreement entered into by the Parties.

13.2 This Agreement shall be governed by and interpreted in accordance with the laws of Canada and Manitoba.

13.3 No member of the House of Commons or of the Senate of Canada or of the Legislature of Manitoba shall be admitted to any share or part of this Agreement, or to any benefit arising therefrom.

13.4 If for any reason a provision of this Agreement, that is not a fundamental term, is found by a court of competent jurisdiction to be or to have become invalid or unenforceable, in whole or in part, it will be severed and deleted from this Agreement, but all the other provisions of this Agreement will continue to be valid and enforceable.

13.5 This Agreement may be executed in counterparts, in which case (i) the Parties have caused this Agreement to be duly signed by the undersigned authorized representatives in separate signature pages in accordance with the following signature process, which together shall constitute one agreement, and (ii) the Parties agree that facsimile signature(s) and signature(s) transmitted by PDF shall be treated as original signature(s). Electronic signature(s) may be accepted as originals so long as the source of the transmission can be reasonably connected to the signatory.

IN WITNESS WHEREOF the Parties have executed this Agreement through duly authorized representatives.

SIGNED on behalf of Canada by the Minister of Health

The Honourable Mark Holland, Minister of Health

SIGNED on behalf of Canada by the Minister of Mental Health and Addictions and Associate Minister of Health

The Honourable Ya'ara Saks, Minister of Mental Health and Addictions and Associate Minister of Health

SIGNED on behalf of Manitoba by the Minister of Health, Seniors and Long-Term Care

The Honourable Uzoma Asagwara, Deputy Premier and Minister of Health, Seniors and Long-Term Care

SIGNED on behalf of Manitoba by the Minister of Housing, Addictions and Homelessness

The Honourable Bernadette Smith, Minister of Housing, Addictions and Homelessness and Minister responsible for Mental Health

Annex 1 – Common Statement of Principles on Shared Health Priorities

Common Statement of Principles on Shared Health Priorities

Annex 2 – Shared pan-Canadian interoperability roadmap

Figure 1 - Text Description

5-Year Shared Pan-Canadian Interoperability Roadmap

The Roadmap outlines 8 categories of activities planned for fiscal years 2023 to 2027, followed by anticipated outcomes enabled. Notes are also included throughout to highlight a "milestone", where "vendor input is required", and/or when an activity is "continued" across multiple fiscal years.

Patient Summary

• Fiscal Year 2023
  • Alberta & Ontario Trial Implementation & onboard 2-3 Jurisdictions
  • Update based on Trial Implementations
  • Update and publish the Canadian Health Data Exchange (CA:FeX) Specification
• Fiscal Year 2024
  • Update specification to fully align to IPS/CA Core+ and reflect implementation feedback
  • Onboard remaining jurisdictions
  • Publish vendor conformance requirements and represent in national procurements [vendor input required]
• Fiscal Year 2025
  • Advance implementation and adoption
  • Pan-Canadian vendor compliance service *(Pan-Canadian interoperability compliance testing service in place, vendors conform to pan-Canadian standards in stages.) [vendor input required]
• Fiscal Year 2026
  • Advance implementation and adoption [continued]
  • Conduct performance evaluation
  • Update specification to reflect updated CA Core+ [milestone]
• Fiscal Year 2027
  • Advance implementation and adoption [continued]
  • Conduct performance evaluation [continued]

Data Portability

• Fiscal Year 2023
  • Develop Primary Care Dataset V1 & EMR Extract Specification V1 [milestone]
  • Represent Data Portability components in the Canadian Health Data Exchange (CA:FeX) Specification
• Fiscal Year 2024
  • Trial Implementation of specifications
  • Extend CA Core+ to include other settings (e.g. Acute Care, Mental Health)
• Fiscal Year 2025
  • Expand adoption and refinement to include LTC, Community Care and implementation feedback
  • Include requirements in national procurements (e.g. Acute Care, LTC, Mental Health, Community Care)
• Fiscal Year 2026
  • Expand adoption of Specifications
  • Complete specifications [milestone]
  • Pan-Canadian vendor compliance service *(Pan-Canadian interoperability compliance testing service in place, vendors conform to pan-Canadian standards in stages.) [vendor input required]
  • Conduct performance evaluation
• Fiscal Year 2027
  • Expand adoption of Specifications [continued]
  • Conduct performance evaluation [continued]

Patient Access

• Fiscal Year 2023
  • Assess patient data and access needs across jurisdictions
  • Assess the feasibility of IPA standard and decide on Canadian adoption of same
• Fiscal Year 2024
  • Co-design patient data access design/Blueprint to represent policy and consent in alignment with IPA
  • Implementation and refinement of the Canadian Health Data Exchange Specification to include Patient Access components [milestone]
• Fiscal Year 2025
  • Update data exchange specification to support patient Digital Identities
  • Expand adoption of Canadian Health Data Exchange Specification
• Fiscal Year 2026
  • Develop pan-Canadian guidance documentation for basic digital consent
  • Expand adoption of Canadian Health Data Exchange Specification [continued]
  • Conduct performance evaluation 
• Fiscal Year 2027
  • Develop advanced guidance documentation to integrate policy and consent into data access
  • Expand adoption of Canadian Health Data Exchange Specification [continued]
  • Conduct performance evaluation [continued]

eReferral & eConsult

• Fiscal Year 2023
  • Consolidate existing specifications and publish pan-Canadian specification with procurement requirements [milestone]
• Fiscal Year 2024
  • Publish conformance requirements for vendors [vendor input required]
  • Implementation of pan-Canadian specifications
• Fiscal Year 2025
  • Evolve specification to integrate other services (e.g. PS-CA. Provider Directories and Digital Identities)
  • Pan-Canadian vendor compliance service *(Pan-Canadian interoperability compliance testing service in place, vendors conform to pan-Canadian standards in stages.) [vendor input required]
• Fiscal Year 2026
  • Complete Specification [milestone]
  • Conduct performance evaluation [continued]
• Fiscal Year 2027
  • Conduct performance evaluation [continued]

Enablers

• Fiscal Years 2023 to 2027
  • Governance
  • Change Management
  • Vendor Mobilization

Data

• Fiscal Year 2023
  • p-CHDCF, CA Core+ and Consistent Data Semantics
  • Data Matching
• Fiscal Year 2024
  • p-CHDCF, CA Core+ and Consistent Data Semantics [continued]
  • Data Matching [continued]
• Fiscal Year 2025
  • p-CHDCF, CA Core+ and Consistent Data Semantics [continued]
  • Data Matching [continued]
• Fiscal Year 2026
  • p-CHDCF, CA Core+ and Consistent Data Semantics [continued]
• Fiscal Year 2027
  • N/A

Access & Exchange

• Fiscal Year 2023
  • Consistent, Secure, HIE Exchange
  • Healthcare Directories and Resource Locations
• Fiscal Year 2024
  • Consistent, Secure, HIE Exchange [continued]
  • Provider Directories
  • Digital Identities & Identity Proofing
  • Healthcare Directories and Resource Locations [continued]
• Fiscal Year 2025
  • Consistent, Secure, HIE Exchange [continued]
  • Provider Directories [continued]
  • Digital Identities & Identity Proofing [continued]
  • Healthcare Directories and Resource Locations [continued]
• Fiscal Year 2026
  • Consistent, Secure, HIE Exchange [continued]
  • Provider Directories [continued]
  • Digital Identities & Identity Proofing [continued]
  • Consistent Patient Access
  • Healthcare Directories and Resource Locations [continued]
• Fiscal Year 2027
  • Consistent, Secure, HIE Exchange [continued]
  • Consistent Patient Access [continued]

Trusted Framework

• Fiscal Year 2023
  • Jurisdictional Needs Assessment [milestone]
  • Scalable Data Sharing Governance Framework
  • Industry-wide, Testing and Conformance
• Fiscal Year 2024
  • TEF development (contingent on PT support)
  • Scalable Data Sharing Governance Framework [continued]
  • Industry-wide, Testing and Conformance [continued]
• Fiscal Year 2025
  • Consistent Representation of Policy & Consent
  • Scalable Data Sharing Governance Framework [continued]
  • Industry-wide, Testing and Conformance [continued]
• Fiscal Year 2026
  • Consistent Representation of Policy & Consent [continued]
  • Scalable Data Sharing Governance Framework [continued]
  • Industry-wide, Testing and Conformance [continued]
• Fiscal Year 2027
  • Consistent Representation of Policy & Consent [continued]
  • Scalable Data Sharing Governance Framework [continued]
  • Industry-wide, Testing and Conformance [continued]

Outcomes

• Ability to import/export primary care data to, from and between EMRs
• Clinicians able to change EMRs
• Governance model established
• Vendor support services available to all jurisdictions
• National procurement framework established
• Change management program in place
• 50% of Canadians enabled to directly access their longitudinal record
• 60% of primary care physicians reporting ability to exchange patient summary record
• 70% of clinicians with EMRs enabled to send clinical summaries through a vendor conformed solution
• 75% of Canadians enabled to access their patient summary record
• Benefits realized:
  • Health System – $500M in improved interactions, effective use of ED, in-patient services, an reduction in duplicate tests
  • Canadians – over $500M in saved patient time
  • Clinicians – over $350M in saved time

Annex 3 – Headline common indicators

Annex 4 – Action plan

1.0 Overview/Background

All Manitobans deserve timely access to quality health care. A commitment to taking better care of people is integral to efforts underway in the health care system. The Government of Manitoba is committed to a new vision in health care by making permanent and foundational changes to improve life for front-line staff and deliver the best quality care to patients. This includes a focus on changing the culture in health care to support retention and recruitment of frontline workers.

Fundamental changes are required to fix the health care system in Manitoba. The COVID-19 global pandemic compounded major pre-existing challenges and created immense strain in Manitoba's health care system. Central to this is a critical shortage of nurses and other frontline health workers. Manitoba is launching a listening tour to support resetting the relationship with the health workforce and to enable collaboration on the challenges ahead.

Wait times and backlogs are another key challenge. Manitobans can face long delays for surgeries and diagnostic tests. They also can endure long wait times for emergency care. The province is taking action with a strategy to increase system capacity with increased beds and improved patient flow.

Federal funding provided through this agreement will be directed toward this core priority work of supporting and growing the health workforce, and building health system capacity to reduce delays and backlogs for health services.

Funding will also support improving access to quality mental health, substance use and addictions services. Manitoba has some of the highest mental health and substance use needs in the country, including the highest rates of suicide of any province. At least 28% of Manitoba adults are dealing with mental illness, and there can be long wait lists for some programs and services. Indigenous peoples in the province experience higher rates of substance use disorder and mental illness. The COVID-19 pandemic has put additional strain on the mental health and well-being of Manitobans, as well as service providers.

Manitoba has a new department of Housing, Addictions and Homelessness mandated to break down barriers and deliver wrap around services to those in need with dignity and compassion. Through this new department, the province will be working to address the complex factors involved in the current addictions crisis. This will include establishing a supervised consumption site in downtown Winnipeg to save lives and connect Manitobans with health care and social supports, and work with experts to create systems for testing toxic drugs.

While this action plan is focused on the shared health priorities of health human resources and backlogs, and mental health and substance use, Manitoba also acknowledges the critical importance of the other shared priorities of family health services, and modernizing the health system. Work is underway to make improvements in both of these areas beyond the scope of this funding agreement.

Primary care is the foundation and entry point to Manitoba's health care system to support timely and appropriate patient-centred care, and to help prevent or reduce more expensive acute care needs. The primary care eco-system in Manitoba includes many types of practitioners, standards, processes and funding structures. More integration and coordination is needed to ensure Manitobans receive more reliable and accessible care when and where they need it. The province is committed to improving family health services, including significantly expanding the health workforce, and opening new health centres staffed by primary care teams.

Manitoba is also working to modernize health service delivery and data systems, and to implement digital solutions across the health system. Technological advancements are needed to support transformation in health service delivery and better care for Manitobans, particularly those in rural and remote areas. Further adoption of digital tools and technologies can support improved care, and strong health information systems are key to help inform decisions on health system improvements. Manitoba is also committed to moving toward consistent and accessible electronic medical records and away from paper charts and fax machines.

Respect for the Canada Health Act and a commitment to uphold the publicly-funded health care system is and will remain a core underlying principle for work underway to improve health services. Manitobans must have equitable access to the services they need based on their medical needs, not their ability to pay.

The Government of Manitoba is strongly committed to resetting the relationship with Métis, Inuit and First Nations leadership in our province. Initiatives outlined in this action plan will help to serve needs in Indigenous populations. Beyond the scope of this agreement, Manitoba is committed to collaboration with local leadership and communities to support new and innovative ways to deliver Indigenous-led and community-based health care in the province. Ongoing and meaningful engagement and partnership with Indigenous governments, rights-holders and Indigenous-led organizations is essential to build strong relationships, and to work together to co-design solutions to support Indigenous health and well-being.

2.0 Description of initiatives – Working Together to Improve Health Care for Canadians

Based on the agreement-in-principle reached between the Manitoba government and the federal government in February 2023, new federal funding to work together to improve health care for Canadians was included in Manitoba's Budget 2023 funding plans for 2023/24. Overall actual health spending in 2023/24 is on track to be well over $700 million more than in 2022/23. Incremental health spending has been directed to range of health system priorities and pressures, including numerous initiatives to support the health workforce and increased system capacity. Federal funding through this agreement is being directed to supporting a portion of these new 2023/24 initiatives as outlined below.

a. Health workforce recruitment and retention

Ensuring a healthy, sustainable health care workforce is a top priority for the Government of Manitoba. This includes changing the culture in health care to ensure workers know their voices are heard, their work is valued and respected, and they have safe and healthy practice environments. As an immediate step, Manitoba has created direct lines of communication between workers at the bedside and government leaders to inform work needed going forward.

Staffing up the system is an essential component of supporting existing health care workers and addressing strains on the health care system. Manitoba will be implementing a new health human resource (HHR) strategy to fix the staffing crisis in health care with a commitment to hiring:

• 400 physicians over 5 years;
• 300 nurses in Winnipeg, with a corresponding commitment to rural and Northern Manitoba;
• 200 paramedics;
• 100 homecare workers; and
• 100 mental health workers.

Multi-pronged work will be undertaken to meet these goals. Underlying this work is a commitment to better serving the needs of all Manitobans. This includes increasing the representation of Indigenous health care providers, and increasing the provision of culturally-safe and informed care models. Manitoba is also committed to improving access to services in French. Consideration will be given to bilingual employee needs as a component of future health human resources planning and strategies as a part of efforts to increase the representation of Francophone and French-speaking health care providers.

New health professionals

Manitoba is undertaking numerous initiatives to expand the health workforce and address staffing shortfalls in critical areas. With the support of funding through this agreement, new recruitment initiatives are beginning or expanding in 2023/24 and will carry through the duration of this action plan as outlined below. Federal funding will be used to support salary costs for essential new health positions, including physicians, nurses and mental health workers, as well as a new recruitment campaign.

The overall cost of these new initiatives to expand the health workforce is estimated to be over $30 million per year by 2025/26, $15 million of which will be supported by federal funding through this agreement.

These initiatives are a part of work toward meeting overall provincial health workforce hiring commitments. In addition to supporting the shared health priority of expanding the health workforce, these initiatives also support improved access to quality mental health and substance use services, expanded access to primary care, and modernization of the health system.

New physicians and recruitment campaign - Manitoba is embarking on a provincial recruitment initiative to hire physicians to support underserved areas. This includes a focus on northern and rural communities. New federal funding will support the ongoing contract wage costs for an initial 60 new physicians to support improved access to care in regions across the province. Federal funding will also support a broad new provincial recruitment campaign that has been launched with an initial focus on digital media. Planning is underway to develop further promotional materials and strategies to complement overall recruitment efforts.

Provincial Nursing Float Pool - Supporting and expanding the nursing workforce is a key ongoing area of focus. This includes investments in the Provincial Nursing Float Pool, a new model that provides nurses with flexibility to work at various locations or facilities across the province, offering nurses a full-time equivalent (FTE) of their choice split between two or more work locations/facilities. This initiative has reported positive outcomes in recruiting nurses back to the public system in which 69% of nurses in the float pool have returned from private agency. Federal funding will support the expansion of the Provincial Nursing Float Pool to reach all health regions, and to expand float pool positions to 400 nurses.

Mental health and substance use - Large areas of the province are experiencing barriers to accessing mental health and addictions care, particularly remote Indigenous communities. Initiatives to expand the health workforce will be focused on addressing this important priority.

Increasing psychologist positions in mental health and tertiary medical areas is a vital step to improve access to care for Manitobans throughout the health system, and to stabilize the current workforce. Manitoba has an acute shortage of clinical health psychologists, with the lowest rate of psychologists nationally. New federal funding will support 12 new positions and will reduce wait times for psychology services for children, youth and adults, improve accessibility and coordination of mental health care, and improve service provision for areas with current limited capacity, including rural areas. Psychiatry positions are also being expanded with new federal investments to help meet demands for mental health services.

Health workforce investments will also be dedicated to supporting mental health and substance use capacity both in community and in the primary care system. Manitoba is hiring more mental health professionals that will work with law enforcement, community safety patrols and community organizations to support community safety and appropriate response to non-violent emergency calls.

Manitoba will also be expanding the Extension of Community Health Outcomes (ECHO) guided-practice model of care to increase capacity and integration of mental health and substance use capacity in primary care.  ECHO improves access to mental health and addictions services for Indigenous peoples and underserved populations by linking expert interdisciplinary teams with primary care clinicians in local communities. The ECHO program builds capacity in management of common mental health and addictions presentations. The use of video-conferencing to provide consultation and information on complex medical and mental health concerns also assists in the reduction of travel for patients and supports health care within remote and First Nations communities.

Front-Line Staffing

Federal funding is being directed to current and future incentives that support recruitment and retention across all provider groups. These incentives recognize the fundamental importance of the health workforce to the overall health system and help support workforce stability. A number of front-line staffing initiatives are underway, including important work to address staffing shortages and vacancies by supporting recruitment, retention, and safe and health practice environments for the health workforce. A range of incentives are in place for health care providers across the province, including hourly premiums, recruitment and retention bonuses, licensure fee reimbursement, and additional wellness benefits. Manitoba also now has a provincial float pool to support nurse staffing needs across the province.

The scope of front-line staffing incentives for health care providers beyond 2023-24 will be determined through dialogue and negotiations with respective health sector unions.

b. System capacity

Overcrowding of emergency departments is a pressing challenge in Manitoba's health care system. Addressing this challenge requires a holistic look at contributing factors and both short and longer term strategic interventions. Viewing access blocking as a "whole hospital" problem demonstrates that capacity or efficiency improvement of 1-3% can have a profound impact on emergency department wait times.

The current shortage of acute care beds is exacerbating congestion and overcrowding in emergency departments. Without the necessary beds, patients experience prolonged stays in the emergency department, which compromises patient care, puts additional strain on health care professionals and hinders the overall efficiency of the health care system. Without the ability to transfer patients to the appropriate acute care unit, their access to the "right" care is delayed, and healthcare professionals must care for both incoming patients as well as those waiting to be transferred.

Manitoba is taking action to improve patient care and reduce emergency room congestion. With the support of funding through this agreement, several new system capacity initiatives are launching in 2023/24 and expanding through the duration of this action plan. Federal funding will support expansions in beds and surgical capacity, and other key initiatives to expand capacity and improve patient care as outlined below. The overall cost of these new initiatives is estimated to be over $80 million per year by 2025/26, $32.9 million of which will be supported by federal funding through this agreement.

Increasing acute care beds – Federal funding will be directed to support new acute care beds as a part of a strategic plan to increase system capacity and the number of acute care beds at various hospitals throughout the province. An initial expansion of beds has been announced at the Grace Hospital to add 10 new medicine beds and 11 new surgical before the end of 2023/24. Another 10 medicine beds will be added in 2024/25. An additional 36 new acute care beds are being added at St. Boniface Hospital, as well as seven new medicine and two new general surgery beds at the Dauphin Regional Health Centre. Further announcements are forthcoming that will bring the number of new acute care beds to at least 151. Expansions will be phased to help ensure the beds are resourced and staffed as they come online.

Allied Health 7 days/week - Critical challenge in hospital throughput stem from both a shortage of appropriate beds and a significant staffing decrease on the weekends. This contributes to fewer discharges Saturday, Sunday, Monday and statutory holidays. The lack of Allied Health supports 7 days a week is also a known cause of longer lengths of stay. Manitoba is adding Allied Health positions (physiotherapists, occupational therapists, social workers, health-care aides) and hospital case co-ordinators to add capacity and expand patient discharges from five to seven days per week in Winnipeg, Brandon and Selkirk. Federal funding will be directed to support these new positions that will help to ensure patients do not spend more time in the hospital than is necessary, which has resulted in overcrowding and higher wait times in emergency rooms and urgent care centres.

Spine surgery expansion - Spinal surgery has significant backlogs with some patients waiting years. During the COVID pandemic, many spinal surgeries were delayed. With support of new federal funding, Manitoba will be advancing several initiatives to expand capacity, improve coordination and address the spinal surgery backlog. This includes expansion of the Minimally Invasive Spine Surgery Program at Brandon Regional Health Centre and the Neuro Rapid Access Spine Surgery Clinic at Health Sciences Centre. Capacity will also be added with establishment of a Spine Surgery Program at Concordia Hospital to significantly improve throughput of spine surgery cases.

Expand Orthopedic and Urology Surgical Slates – Surgical slate capacity at Grace General Hospital is being increased by ten slates per four-week cycle with support from new federal funding through this agreement. This change will fully utilize the hospital's surgical theatre suites and expand bed use for Monday to Friday hours. This will increase orthopedic and urology surgical slates by forty per cent for same-day procedures at the hospital.

Alternate Isolation Accommodation (AIA) – Manitoba is doubling current AIA from 13 rooms to 26 with support of federal funding.  AIA began during the pandemic to support patients with COVID-19 (as well as post-COVID) and patients before their hospital procedures to ensure they remained COVID-free. AIA is still operational with 90% of individuals cared for being people who are experiencing homelessness making discharge back to the community challenging. Many of these individuals have chronic medical conditions requiring complex wound care, ongoing IV therapies, and specialist follow-up, and/or some form of addiction or recovery from addiction, previous trauma, and/or other mental health needs. Shelters will not accept COVID-positive individuals even after discharge from the hospital. As a result, these patients are unnecessarily in hospital for as much as a week or longer which contributes to emergency department overcrowding and presents a significant expense to the health system. Expansion of AIA is a short-term measure to support patient flow as broader work is underway to expand community care capacity and end chronic homelessness in the province.

3.0 Description of initiatives – Mental Health and Substance Use

Manitoba's new department of Housing, Addictions and Homelessness is leading provincial efforts in increase access to quality mental health, harm reduction and substance use services. This includes a commitment to offering wrap around supports, listening to experts for best practices in prevention, harm reduction and treatment, and promoting education to support destigmatizing addictions.

Manitoba will also be implementing a province-wide Suicide Prevention Strategy which will include a focus on 2SLGBTQ+ youth. While development of a comprehensive suicide prevention strategy is underway, Manitoba is focusing early actions on Indigenous youth programming and the development of networks. Plans for 2024/25 include Indigenous engagement and completion of the Suicide Prevention Strategy with the guidance of an advisory group and input from key stakeholders. Future implementation of the Suicide Prevention Strategy will require a cooperative approach with Indigenous and federal partners to support suicide prevention and mental health crisis service programming in First Nations communities.

These efforts will build on initiatives supported with ongoing federal funding for mental health and addictions. These initiatives will continue to focus on key government priorities that enhance coordinated access to care for addictions, harm reduction and mental health services across the province. Key priorities include increasing system capacity to address wait times and access challenges including supporting access to culturally relevant treatment options.

Federal funds will continue to support enhanced capacity in addictions, community and mental health services. The focus of the funding will be on expanding addictions treatment options, peer support in formal health settings ($5.4 million in federal funds over 3 years), enhancing community drop in services and programming for individuals with mental health and addictions challenges. Federal funds will also support priority populations such as children and youth, 2SLGBTQ+ communities and Indigenous peoples, with $7.8 million in federal funding over 3 years going toward initiatives focused on Indigenous populations. These initiatives are:

Increasing timely access to coordinated care for mental health and addictions services

Federal funds will continue to support improved coordination of and access to addictions and mental health supports across the province. Key priorities include increasing the capacity of mental health and addictions services throughout the province; improving access and coordination of the mental health and addictions system; and decreasing wait times for services.

Federal funding supports numerous community-based initiatives that support mental health and wellness, and more timely access to coordinated care for all age groups, including focus on priority populations such as children and youth, and Indigenous peoples. Federal funds also support enhanced access to child and youth mental health emergency, assessment and treatment services, as well as provision of culturally relevant treatment options; prevention and early intervention programs for children and youth; integrated youth services; more timely access to withdrawal management services; improved opportunities for prescribers to enhance their competencies in addiction medicine; and increased access to treatment through Rapid Access to Addictions Medicine (RAAM) clinics.

Implementation of peer support in formal healthcare settings

Federal funds will continue to support community-based agencies to deliver formal peer and family support services in emergency departments and in Winnipeg's Crisis Response Centre. Focus here is on Indigenous youth, supporting mentorship of a peer support worker and enhanced access to mental health/addictions support, social service support, and educational engagement. This includes increased awareness and utilization of peer support as a response to crisis scenarios, and improved continuity of services between emergency settings and the community.

Services focused on Indigenous Populations

Federal funds will also continue to support Granny's House, which provides 24/7 respite services to families from the North End of Winnipeg who are at risk of involvement with the child and family services system, with priority for supports to Indigenous families. The goals of the program are to improve mental wellness for parents and caregivers and to reduce child and family services involvement for participating children and families. Funding also supports an Indigenous-led treatment and healing programs providing individualized care for youth using culturally safe, relationship-based, and trauma-informed methods. Manitoba has further supported the implementation of an Indigenous-led Rapid Access to Addictions Medicine (RAAM) clinic in Winnipeg to improve access to culturally relevant treatment options.

These priorities align with the previous Common Statement of Principles on Shared Health Priorities by:

• Expanding access to community-based mental health and addiction services for children and youth (age 10-25), recognizing the effectiveness of early interventions to treat mild to moderate mental health disorders;
• Expanding addictions treatment capacity and integrating mental health services with primary care; and
• Expanding availability of integrated community-based mental health and addictions services for people with complex health needs.