Canada-Northwest Territories 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 -

GOVERNMENT OF THE NORTHWEST TERRITORIES (hereinafter referred to as "the Northwest Territories" or "Government of the Northwest Territories") as represented by the Minister of Health and Social Services (herein referred to as "the territorial Minister")

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

PREAMBLE

WHEREAS, on July 6, 2023, Canada and the Northwest Territories 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, substance use, and addictions 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 the Northwest Territories 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, the Northwest Territories 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 Hospital Insurance and Health and Social Services Administration Act authorized the territorial Minister to enter into agreements with the Government of Canada under which Canada undertakes to provide funding toward costs incurred by the Government of the Northwest Territories 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 the Northwest Territories 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 the Northwest Territories 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 the Northwest Territories 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 draft 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 the Northwest Territories 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 the Northwest Territories 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 the Northwest Territories agree that, with financial support from Canada, the Northwest Territories 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 the Northwest Territories agree that, with Budget 2017 financial support from Canada outlined in 5.2.2, the Northwest Territories 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 The Northwest Territories 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 The Northwest Territories 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 The Northwest Territories 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, the Northwest Territories 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 The Northwest Territories' 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, the Northwest Territories 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 territory.

5.2 Allocation to the Northwest Territories

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 1^st 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 1^st 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 1^st 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 1^st from Statistics Canada;

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

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

2. 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 the Northwest Territories, as determined using the annual population estimates on July 1^st from Statistics Canada; and

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

5.2.4 Subject to annual adjustment based on the formulas described in section 5.2.3, the Northwest Territories estimated share of the amounts will be:

Working Together to Improve Health Care for Canadians

Fiscal Year	Estimated amount to be paid to the Northwest TerritoriesFootnote * (subject to annual adjustment)	Budget 2017 Mental Health, Substance Use, and Addictions Services Estimated amount to be paid to the Northwest TerritoriesFootnote * (subject to annual adjustment)
2023-2024	$ 7,360,000	$ 700,000
2024-2025	$ 7,360,000	$ 700,000
2025-2026	$ 7,360,000	$ 700,000
* Amount represent annual estimates based on Statistics Canada's July 1st, 2022, population estimates. Return to footnote * referrer

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 the Northwest Territories 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 the Northwest Territories of the amount of the second installment as determined under sections 5.2.3 and 5.2.4.
6. Canada shall withhold payments if the Northwest Territories has failed to provide reporting in accordance with 7.1.
7. Canada shall withhold the second payment in 2023-24 if the Northwest Territories has failed to satisfy all reporting requirements associated with the preceding Canada – Northwest Territories 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 Department of Health and Social Services' Financial Officer, of funding received the preceding Fiscal Year from Canada for mental health and addiction services under the Canada – the Northwest Territories 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, the Northwest Territories 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 the Northwest Territories under subsection 5.2.4 of this Agreement in the next Fiscal Year.

5.4.3 Upon request, the Northwest Territories 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 the Northwest Territories 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 the Northwest Territories 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, the Northwest Territories 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 the Northwest Territories 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 The Northwest Territories 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, the Northwest Territories 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 Northwest Territories 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 Department of Health and Social Services' 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 The Northwest Territories 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 The Northwest Territories will ensure that expenditure information presented in the annual financial statement is, in accordance with the Northwest Territories' standard accounting practices, complete and accurate.

7.3 Evaluation

7.3.1 Responsibility for evaluation of programs rests with the Northwest Territories 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 The Northwest Territories will make publicly available, clearly identified on a Government of Northwest Territories website, this agreement, including any amendments.

8.5 Canada, with prior notice to the Northwest Territories, 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 the Northwest Territories 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 the Northwest Territories 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 The Northwest Territories reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the Common Statement and this Agreement. the Northwest Territories 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 the Northwest Territories agree to participate in a joint announcement upon signing of this Agreement.

8.9 Canada and the Northwest Territories 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 the Northwest Territories responsible for health, and if it cannot be resolved by them, then the federal Minister(s) and the territorial 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 the Northwest Territories, by the territorial 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 the Northwest Territories shall be:

Assistant Deputy Minister, Finance, Policy and Planning Branch

Tatsaotı̨̀ne Building, 7th Floor
5015 - 49th Street
P.O. Box 1320
Yellowknife, NWT
X1A 2L9

Email: Jeannie_Mathison@gov.nt.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 the Northwest Territories.

13.3 No member of the House of Commons or of the Senate of Canada or of the Legislature of the Northwest Territories 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 counterparts together shall constitute one agreement, and (ii) communication of execution by fax transmission or emailed in PDF shall constitute good delivery. 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 the Northwest Territories by the Minister of Health and Social Services.

The Honourable Julie Green, Minister of Health and Social Services

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

Shared health priority area	Indicator
Family health services	Percentage of Canadians who report having access to a regular family health team, a family doctor or nurse practitioner, including in rural and remote areas
Health workers and backlogs	Size of COVID-19 surgery backlog
	Net new family physicians, nurses, and nurse practitioners
Mental health and substance use	Median wait times for community mental health and substance use services
	Percentage of youth aged 12 to 25 with access to integrated youth services (IYS) for mental health and substance use
	Percentage of Canadians with a mental disorder who have an unmet mental health care need
Modern health data system	Percentage of Canadians who can access their own comprehensive health record electronically
	Percentage of family health service providers and other health professionals (e.g., pharmacists, specialists, etc.) who can share patient health information electronically

Annex 4 – Action plan

Overview

The Department of Health and Social Services, along with the three Health and Social Services Authorities, are one integrated territorial Health and Social Services (HSS) System, functioning under a one-system-approach and under a single governance structure. Non-governmental organizations and community and Indigenous governments also play a key role in the delivery of health and community wellness activities and services, including prevention and promotion, on behalf of the Department and the Authorities.

There are 33 communities across the Northwest Territories, ten communities have less than 200 residents, and only six have over 1,000 residents. The population density represented by these 33 communities is 0.04 persons/km2. In terms of accessibility, four communities are without highway access, and 10 communities have winter highway access only. As a result, delivery of health services is challenging particularly in smaller communities with limited staff and capacity, and further strained during unexpected increases in demand.

Long-term sustainability of the HSS System is a challenge, with increasing service demands and costs. Based on projections from the Canadian Institute of Health Information (CIHI), the 2021 total health spending (public and private) per NWT resident ($20,365) is over 2.5 times higher than the average per Canadian. The high cost per NWT resident can be attributed to increasing costs of services and increasing volumes of patients accessing services. The NWT population fares worse in several lifestyle indicators such as: daily smoking, heavy drinking, and obesity. These can all have serious short-term and long-term consequences such as injury, cancer, circulatory, and other chronic diseases and are often linked to poorer social determinants of health. As the HSS System evolves, there are increasing opportunities to mitigate costs through a one-system approach in support of shared services and initiatives, program and service reform, and continued attention to prevention activities.

NWT is allocating funding available through the Agreement to Work Together to Improve Health Care for Canadians to target strategic goals of the HSS System, where resources will support the continuation of efforts to improve the health of the population and equity of outcomes and make strides in attracting and retaining stable and representative health human resources, as well as address system gaps. The NWT HSS System's goal to improve the health of the population is achieved through focused efforts on health promotion, disease prevention and targets access to programs and services for high-risk populations. A stable and representative workforce requires an available and appropriate workforce supply. The NWT, similar to the rest of Canada, is challenged to recruit and retain the necessary workforce for the effective and efficient delivery of services. The lasting impacts of COVID-19 pose further challenges to recruitment and retention within the HSS System, given its impacts on existing staffing shortages, work-life balance, and the mental health of the workforce. The recent NWT HSS System Human Resources (HR) Plan represents a collaborative approach to strategic human resource planning and support across the entire HSS System.

The Government of the Northwest Territories (GNWT) has identified four initiatives for federal investment within three priority areas. While each of these areas has a specific objective, there is significant intersection as the resources are funding a relatively small NWT HSS System and investments in one area support work in another area. All these initiatives are incremental to programming currently underway and funded by the GNWT. The NWT HSS System operates with a significant accumulated and increasing annual deficit; without this federal investment, these enhancements would not be possible.

Investment in family health services

Shared objective: Canadians have timely access to high quality, effective, and safe health services.

Initiative #1 – Territorial Public Health Transformation

Description of activities

The GNWT will establish a territorial public health unit (TPHU) and the federal investment will fund approximately 22 FTEs located throughout the NWT. The intent of the TPHU is to support operational oversight and set direction to an increased public health regional capacity. This will ensure equitable access to services across the NWT, as the TPHU will work with integrated primary care teams to minimize duplication of services and improve health outcomes by improving capacity and coordination of core public health functions. A strengthened public health capacity integrated with primary care service delivery is expected to reduce high rates of ambulatory sensitive hospital admissions and provide more effective and timely client care. Increased public health capacity will also support improved outcomes and services delivered in primary care settings, such as prenatal care and result in freeing up primary care providers to be able to provide the right care at the right time to meet client needs. Designated physician and nurse practitioner support in public health will address gaps in developing medical directives, supporting primary care practitioners in education (ex. staging syphilis) and building much needed guidelines for front-line teams to support in the workload of practitioners.

Rationale

The COVID-19 pandemic exposed the vulnerability of the NWT HSS System to effectively respond to public health emergencies and made evident the need for continuous improvements to public health coordination and service delivery. The pandemic highlighted that when large scale public health events occur, there is a significant strain on primary care operations and the public's access to non-emergency care. Investing in core public health services will strengthen primary health care systems by contributing to safe and high-quality care.

According to CIHI, the NWT spends the least (8.4%) of the three territories on public health programs and services. Nunavut spends 10.1% of its overall budget; Yukon spends nearly double the NWT, at 14.9%.

At 40.4% of total health care spending, the NWT spends more on hospital care than any other province or territory in Canada and much more than the Yukon at 23.6%; Nunavut spends 36.3%. A focus on preventative measures is intended to reduce the need for expensive interventions, treatments, chronic disease management or lifelong care for individuals with preventable congenital diseases, thus reducing the pressure on acute and primary care services.

Relation to broader initiatives

Faced with challenges such as poor population health outcomes, widespread geography, and ballooning health care costs in the face of significant fiscal limitation, the NWT is working to remodel its primary health care delivery, which includes a comprehensive public health delivery team. Primary health care reform is focused on creating a system that provides residents with the right care, from the right provider, at the right time and place through the delivery of culturally safe and relationship-based health and social services. The creation of the TPHU is integral to the work being done under primary health care reform in that TPHU is part of an integrated service delivery team that has the client and their family at the centre of service delivery.

Addressing the needs of Indigenous peoples and other underserved and disadvantaged populations

The HSS System works to address effects of colonialism and systemic racism through a wide range of services and continuous training. Activities planned under this priority area aim to support provision of quality public health care across the NWT regions; for example, it is known that cancer rates in regional centres, where there are more Indigenous residents, are higher than in Yellowknife per 2012-2016 data. Population health data identifies areas for increased focus which, in turn, will direct the TPHU to increase support regional staff to undertake surveillance (screening), programming and services. A portion of the federal investment under this initiative will fund seven new regional public health positions.

Health workers and backlogs

Shared objective: Canada has a sustainable, efficient, and resilient health workforce that provides Canadians with timely access to high quality, effective, and safe health services.

Initiative #2 - NWT HSS System Human Resources Plan

Description of activities

The NWT HSS System Human Resources (HR) Plan was released June 3, 2022. The HR Plan represents a collaborative approach to strategic human resource planning and support across the entire HSS System, including the Department of Health and Social Services (DHSS) and the three HSS authorities - the Hay River Health and Social Services Authority (HRHSSA), the Northwest Territories Health and Social Services Authority (NTHSSA), and the Tłįchǫ Community Services Agency (TCSA).

While the HR Plan was established to set a course of action for strategic human resource planning, it was acknowledged that additional funding would need to be identified to support the successful delivery of the goals, objectives, and actions of the HR Plan.

Currently, the HSS System funds initiatives such as: the Family Medicine Residency Program, HSS Bursary Program, marketing and promotion that includes recruitment campaigns, conferences and career fairs, and youth outreach/mentorship programming. Additionally, GNWT resources have funded enhanced recruitment and retention efforts through initiatives such as the referral program, labour market supplement, and the friends and family program.

The goals, objectives and actions outlined in the HR Plan address medium and long-term human resource needs of the HSS System, as well as core challenges negatively impacting recruitment and retention.

The HR Plan identifies six strategic goals:

• Informed decision-making related to workforce planning, recruitment and retention
• Developing and supporting Indigenous and northern population in the pursuit of careers in the health and social services field
• Enhanced attraction and recruitment strategies and goals
• Increased employee engagement through organizational change and leadership development
• Support quality training and targeted development
• Enhanced health, safety and wellness support systems

Among the efforts the federal investment will resource are:

• the continuation of the Family Medicine Residency Program. This pilot program has been highly successful, and the federal investment will allow it to continue beyond the first residency cycle;
• 2.0 FTEs to support implementation of a system to track and report on training and compliance within the HSS System including all mandatory and statutory training including cultural safety and anti-Indigenous racism training.
• Training, including mandatory cultural safety and anti-Indigenous racism training, for HSS System staff; and
• 1.0 FTE to support employee engagement to build retention of existing workforce.

Rationale

A national health human resource crisis has significantly impacted the ability to attract and retain health care professionals. The NWT has struggled with recruitment and retention for many years due to the remote nature of health service delivery in the North. However, with this current crisis, competition in the labour market has resulted in the NWT having to implement closures and redirect patients out of territory to access services more regularly.

Relation to Broader Initiatives

The overall strategic direction of the HR Plan is guided by the Government of the Northwest Territories mandate and priorities of the 19th Legislative Assembly; and various GNWT strategic human resource plans and documents including the DHSS Indigenous Employment Plan and the GNWT Diversity and Inclusion Framework. Additionally, the NWT continues to participate in discussion at Federal/Provincial/Territorial tables to address challenges and shared solutions related to health human resources.

Addressing the needs of Indigenous peoples and other underserved and disadvantaged populations

The GNWT supports many initiatives that encourage Indigenous and other under-represented persons to participate in the HSS System as referenced earlier (GNWT Diversity and Inclusion Framework, the Indigenous Career Gateway Program, the Indigenous Employees Advisor Committee, Indigenous Development and Training Program, and the Indigenous Recruitment and Retention Framework). The HR Plan builds upon these initiatives and includes specific goals to increase Indigenous representation in the health and social services fields recognizing that the population of the NWT is more than 50% Indigenous. The HSS System has prioritized and mandated cultural safety and anti-Indigenous racism training for staff, which improves service delivery and helps health care providers with understanding the effects that colonialism and racism have had on health outcomes and Indigenous residents' interactions with the HSS System. This work is foundational to attaining systemic change and impacts the areas funded through this Initiative by embedding a cultural safety anti-racism lens ensuring the HSS System's front line health care providers deliver patient centred care to NT residents.

Mental health and substance

Shared objective: Canadians have access to timely, equitable and quality mental health, substance use and addictions services to support their wellbeing.

Initiative #3 – Territorial addictions medicine program

Description of activities

A Territorial Addictions Medicine Team will be established to provide incremental enhancement to coordination and delivery of shared care by primary, community, acute care, and Mental Health and Addictions staff across the territory for the treatment of Opioid Use Disorder, alcohol withdrawal, and complex polysubstance use.

The first year will be focused on providing inpatient Medical Detox programming and preparing the system for a coordinated approach to clinic and home-based alcohol withdrawal management. Inpatient capacity and pathways are a foundational step prior to implementation of territory-wide outpatient detox services. Year 1 will also be focused on ensuring that existing substance use programs are sufficiently resourced to continue provided services, and initial development and piloting of community-based withdrawal management.

Investments in the second year will allow for the phased expansion of comprehensive outpatient withdrawal management capacity, long-term case management, and community support. Consultations and nursing support for clinic and home-based withdrawal management is provided in a phased roll-out beyond pilot sites to additional community hubs. Development and phased expansion of telehealth and virtual care services also commences in Year 2. Evaluation of capacities and forecasting of future needs is escalated in this year.

Over the three-year period, an additional 24 FTEs will be added to the HSS System for this Initiative, which includes clinical staff with specializations in addictions, supporting the establishment of two dedicated medical detox hospital beds and regional/community-based withdrawal treatment programming.

Rationale

Establishing a model for in-patient medical detox and clinic-based alcohol withdrawal management has been identified as a way to reduce high rates of emergency department and inpatient admissions with a primary or secondary concern related to alcohol use and alcohol withdrawal.

Currently, this gap represents a significant impact to acute care and critical care resources. A coordinated access approach uses common processes, protocols, tools, and improved system navigation to ensure that "any door is the right door."

According to the Canadian Substance Use Costs and Harms Report, in 2017, the total healthcare costs in the NWT related to alcohol consumption was $18.8 million. $1.55 million was attributed to ER visits, $3.77 million to inpatient hospitalizations, and $4.37 million in physician time. In 2017, there were over 4,400 ER visits, 397 inpatient stays, and 71 deaths associated with alcohol use.

Relation to Broader Initiatives

The Territorial Addictions Medicine Team model of care connects trained addictions providers, leverages existing resources, and strengthens our ability to provide specialized services in a more equitable way. The Territorial Addictions Medicine Team aligns with the Stepped Care 2.0 and contributes to the Addictions and Prevention Recovery Services Work Plan and the NWT Alcohol Strategy.

Addressing the needs of Indigenous peoples and other underserved and disadvantaged populations

In 2021-22, the NWT rate of hospitalizations due to substance use harm was over three times the national average (19.0 versus 5.6 per 1,000), where more than eight out of ten of those hospitalizations involved alcohol in the NWT compared to around half nationally. Based on available 2017-18 data, Indigenous people had a rate over five times higher than non-Indigenous peoples, and regional centres were the community type with the highest rates; that is, compared to Yellowknife and smaller communities.

Initiative #4 – Culturally appropriate mental wellness and suicide prevention programming

Description of activities

This initiative will continue to be funded within the budget provided through the 2017-2022 and subsequent 2022-2023 Canada-Northwest Territories Home and Community Care and Mental Health and Addiction Services Funding Agreement and continued through the Agreement to Work Together to Improve Health Care for Canadians. The activities being funded through this Action Plan are consistent with the Common Statement of Principles on Shared Health Priorities established on August 21, 2017.

Three dedicated positions continue to be funded under this initiative. The positions administer the Community Suicide Prevention and Community Wellness and Addictions Recovery Funds, which includes dedicated support to communities and Indigenous Governments/organizations for program planning, proposal writing, and reporting. The Funds help ensure there are enhanced options across the continuum of care including community-based prevention initiatives. Additionally, the Funds support Indigenous Governments and community organizations as they strengthen community level responsiveness, and design and delivery of culturally safe and appropriate programs as they exercise self-determination.

In addition to continued delivery of targeted training to improve the implementation of the Suicide Risk Assessment tool, and the oversight and activation of the Territorial Crisis Response Network, the investment in these positions provides for enhanced connection with Indigenous Governments/organizations as they bring people together to support the implementation of a Territorial Community of Practice.

Rationale

Indigenous communities are disproportionately impacted by deaths by suicide in the NWT. The recent spike in the number of suicides in the NWT had a devastating impact on many of NWT's small, remote communities.

The establishment of the Suicide Prevention and Crisis Response Network in 2017 addressed three key areas: Prevention, Intervention and Postvention. Positions to carry out the work as well as available resources for communities' program planning (proposal writing, reporting and community of practice) will continue under the key areas.

Enhanced training and an understanding of how to conduct suicide risk assessments and engage in safety planning in a culturally sensitive manner is critical, as is providing ongoing support to communities not only in times of crisis, but to support ongoing prevention activities.

The importance of community-based, culturally safe and relevant programming cannot be overstated, and Indigenous Governments are key partners in mental wellness and suicide prevention initiatives.

Relation to Broader Initiatives

Suicide prevention is a key consideration for the 19th Legislative Assembly. In response to a high number of suicides in 2022, the Standing Committee on Government Operations made several recommendations related to suicide prevention in the spring of 2023. These recommendations included increasing the funding available through the Community Suicide Prevention Fund, and ensuring the Fund is a low barrier fund that is easy for communities to access.

Addressing the needs of Indigenous peoples and other underserved and disadvantaged populations

Suicide Prevention activities should be community driven and take a grassroots approach to overall community wellness and anti-stigma. These funds prioritize Indigenous governments and provide a level of flexibility that allows communities to identify their own needs and values for Indigenous healing and ways of knowing.

This aligns with the Truth and Reconciliation Commission of Canada's Calls to Action and the United Nations Declaration on the Rights of Indigenous Peoples both of which reference the right of indigenous peoples to determine and develop their own priorities and to administer programs (health, social, etc.) through their own institutions.

Measuring and reporting on results

In addition to reporting through established annual and business planning processes, a reporting on indicators will occur through the public website of the Department of Health and Social Services.