Canada-Quebec Emergency Treatment Fund Agreement
HER MAJESTY THE QUEEN IN RIGHT OF CANADA (hereinafter referred to as “Canada” or “Government of Canada”) as represented by the Minister of Health (hereinafter referred to as “the federal Minister”)
- and -
The government of Quebec as represented by the Minister of Health and Social Services, the Minister for Rehabilitation, Youth Protection, Public Health and Healthy Living, and the Minster responsible for Canadian Relations and the Canadian Francophonie (hereinafter referred to as “Quebec”)
REFERRED to collectively as the “Parties”
WHEREAS Canada and Quebec agree that Canada is in the midst of an opioid crisis that has had a significant effect on many communities, that has claimed the lives of thousands of Canadians from all walks of life, and that has had a devastating impact on many Canadian families;
WHEREAS Canada and Quebec agree that immediate action is needed to help reduce harms and deaths associated with problematic substance use, including opioids;
WHEREAS Canada has established a transfer payment program called the Emergency Treatment Fund to provide one-time funding to the provincial and territorial governments for the delivery of treatment services for problematic substance use, including opioids;
NOW THEREFORE, Canada and Quebec agree as follows:
1.1 The purpose of this Agreement is to provide financial support from Canada to Quebec to support and enhance treatment services for problematic substance use, including opioids. This funding will support single or multi-year Quebec projects that will build on existing initiatives, capacity, and priorities.
2.0 Emergency Treatment Services
2.1.1 Canada and Quebec agree that over the period of this Agreement, Quebec will use the funding from Canada to reduce opioid-related harms and deaths by offering and enhancing Quebec treatment services and programs to improve the availability and accessibility of treatment for problematic substance use as set out in the Quebec Action Plan. Quebec’s Action Plan, which sets out the objectives and measures that Quebec will implement, is attached as Annex 1.
2.2 Eligible Areas of Investment
2.2.1 Quebec agrees to allocate funds provided by Canada under this Agreement in one or more of the following eligible areas of investment:
- Support initiatives that will establish, build on, or enhance existing treatment approaches;
- Encourage further implementation of innovative treatment solutions;
- Recognize the importance of broader strategies to support access to treatment services by enhancing health care providers’ knowledge of best practices.
2.2.2 The types of initiatives for which Quebec agrees to use the funding may include: enhancements to or expansion of existing treatment approaches such as opioid agonist treatments (e.g., methadone, buprenorphine/naloxone), withdrawal management products (e.g., opioid agonist taper and alpha2-adrenergic agonists), oral Naltrexone, psychosocial treatment interventions, and counseling services; innovative treatment solutions such as wrap‑around care and injectable agonist therapies; and, implementation strategies to enhance health care providers’ knowledge of best practices.
2.2.3 Treatment services specifically to address alcohol, cannabis, and tobacco are excluded from this funding.
2.2.4 Types of eligible expenditures may include:
- Operating costs;
- Capital costs;
- Training, professional development and related investments;
- Information technology and related investments; and,
- Other costs that in the opinion of the Parties are essential for the completion of the project and achievement of results.
2.2.5 Canada and Quebec also agree to promote, define, and deliver identifiable innovative approaches to treatment service delivery.
3.0 Period of Agreement
3.1 This Agreement shall come into effect upon the last signature being affixed and will remain in effect until March 31, 2023, unless terminated in writing by Canada or Quebec, in accordance with the terms and conditions set out in section 10 of this Agreement. Funding provided under this Agreement, in accordance with section 4, will cover the period from April 1, 2018 to March 31, 2023.
4.0 Financial Provisions
4.1 The funding provided under this Agreement is in addition to, and not in lieu of, that which Canada currently provides to Quebec through the Canada Health Transfer in order to support health care services within Quebec.
4.2 Allocation to Quebec
4.2.1 Canada has designated the following maximum one-time amount of funding to be transferred in total to all provinces and territories under this Agreement: $150,000,000 for the period starting on April 1, 2018 and ending on March 31, 2023.
4.2.2 Quebec agrees to match Canada’s contribution at a 1:1 ratio, with the exception of the first $250,000 in federal funding, for which no cost-sharing is required. Quebec’s matching contribution shall be the equivalent to Canada’s contribution less $250,000 and, as outlined in Annex A, can include eligible expenditures made specifically for treatment related to problematic substance use as of January 1, 2016. Quebec agrees to make every reasonable effort to ensure that previous, ongoing funding from Canada under other programs or agreements will not be used to match Canada’s contribution under this agreement.
4.2.3 Based on the formula described in section 4.2.2, Quebec’s share of the amounts identified in section 4.2.1 will be:
|Fiscal Year||Amount to be paid from Canada to Quebec||Matching amount by Quebec, including eligible expenditures made since January 1, 2016|
4.3 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.
4.4.1 Canada’s contribution under this Agreement will be paid within approximately 30 business days of both Parties’ signatures being affixed to this Agreement.
4.4.2 Quebec must spend the entire amount of Canada’s contribution by no later than March 31, 2023.
4.4.3 Quebec must spend the entire amount of Quebec’s matching contribution by no later than March 31, 2023.
4.4.4 Payment of Canada’s contribution under this Agreement is subject to an annual appropriation by the Parliament of Canada for this purpose.
4.5 Repayment of overpayment
4.5.1 Canada and Quebec agree that every effort will be made to ensure that the calculation of Canada’s contribution installment to Quebec will be accurate.
4.5.2 In the event payment made to Quebec exceeds the amount to which Quebec is entitled under this Agreement, the amount of the excess is a debt due to Canada and Quebec shall repay the amount to Canada within 90 calendar days of written notice from Canada.
4.6 Repayment of other funds
4.6.1 In the event that Quebec does not clearly demonstrate that funds have been cost-matched to the federal funding on a 1:1 ratio less $250,000 by March 21, 2023 in accordance with section 4.2.3, including funding spent since January 1, 2016, Quebec agrees to repay the unmatched funds to Canada within 90 calendar days of written notice from Canada.
4.7 Use of Funds
4.7.1 Quebec agrees that funds provided by Canada under this Agreement will only be used in accordance with the areas for investment outlined in section 2.0 of this Agreement and detailed in Annex 1.
5.0 Accountability and Reporting
5.1 Action Plan
5.1.1 Quebec’s Action Plan for the years 2018-19 to 2022-23 is set out in Annex 1 and will:
- provide an overview of the opioid crisis and planned approach to address problematic substance use in Quebec;
- identify priority areas for investment and objectives, which build upon the progress to date in delivering treatment services;
- highlight those investments Quebec will make in a cost-shared manner equivalent to the federal contribution less $250,000, including investments in initiatives implemented as of January 1, 2016;
- outline the mechanisms, including indicators and targets, that Quebec will use to report annually and publicly on its initiatives to reduce opioid‑related harms and deaths.
5.1.2 The Action Plan may be amended by Quebec within the framework of an amendment of this Agreement entered into with Canada, in accordance with section 8.1, and will be made publicly available in accordance with section 6.2.
5.2.1 Beginning in fiscal year 2019-2020 and by no later than October 1 of the subsequent fiscal year during the Period of this Agreement, Quebec agrees to:
- Report annually to Canada on the activities and expenditures of the Emergency Treatment Fund allocation until March 31, 2023. The report shall show separately the activities attributable to the funding provided by Canada under this Agreement and those attributable to the matching funding provided by Quebec.
- Provide to Canada an audited financial statement of revenues received from Canada under this Agreement during the preceding fiscal year.
- The revenue section of the statement shall show the amount received from Canada under this Agreement during the fiscal year.
- The total amount of funding used for programs and services under section 2.2.
- If applicable, the amount of any amount carried forward by Quebec under section 4.6.
- If applicable, the amount of any surplus funds that are to be repaid to Canada under section 4.7.
The financial statement shall be prepared in accordance with Canadian Generally Accepted Accounting Principles (GAAP).
5.2.2 In addition to reports on the activities and expenditures made under this Agreement, Quebec shall provide Canada with information and reports, that are public in nature, prepared by Quebec on its initiatives to reduce opioid‑related harms and deaths. Canada may incorporate all or any part or parts of these reports, properly citing the source, into any public report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.
5.3.1 Quebec will ensure that expenditure information presented in the annual report is complete and accurate in accordance with Quebec standard accounting practices.
5.4.1 As per established policies and processes with respect to program effectiveness, Quebec will evaluate programs and services receiving funds provided under this Agreement and make public the results of any such evaluations through its reporting process to the National Assembly of Quebec.
6.1 Canada and Quebec agree on the importance of communicating with citizens about the objectives of this Agreement in an open and transparent, manner through appropriate public information activities.
6.2 Canada will make publicly available the Emergency Treatment Fund bilateral agreements entered into with each province and territory, including any amendments thereto, on a Government of Canada website.
6.3 Each government will receive the appropriate credit and visibility when investments financed through funds granted under this Agreement are announced to the public.
6.4 Canada reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the bilateral agreements.
6.5 Quebec and Canada agree to give the other Party 10 days advance notice and advance copies of public communications related to this Agreement, and results of the investments of this Agreement.
7.0 Dispute Resolution
7.1 Canada and Quebec 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.
7.2 If at any time either Canada or Quebec 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, Canada or Quebec, as the case may be, may notify the other Party in writing of the failure or breach. Upon such notice, Canada and Quebec will endeavor to resolve the issue in dispute bilaterally through their designated officials at the Assistant Deputy Minister level (hereinafter “Designated Officials”).
7.3 If a dispute cannot be resolved by Designated Officials, then the dispute will be referred to the Deputy Minister of Health Canada and the Deputy Minister of Health and Social Services for Quebec, and if it cannot be resolved by them, then the federal Minister and Minister of Health and Social Services for Quebec shall endeavor to resolve the dispute.
8.0 Amendments to the Agreement
8.1 This Agreement, including the attached annex, may be amended at any time by mutual consent of the Parties. To be valid, any amendments shall be in writing and signed, in the case of Canada, by the federal Minister, and in the case of Quebec, by the Minister of Health and Social Services, the Minister for Rehabilitation, Youth Protection, Public Health and Healthy Living, and the Minster responsible for Canadian Relations and the Canadian Francophonie.
9.0 Equality of Treatment
9.1 During the term of this Agreement, if another province or territory negotiates and enters into an Emergency Treatment Fund Agreement with Canada, or negotiates and enters into an amendment to such an agreement and if, in the reasonable opinion of Quebec, any provision of that agreement or amended agreement is more favorable to that province or territory than the terms set forth in this Agreement, Canada agrees to amend this Agreement in order to afford similar treatment to Quebec, if requested by Quebec. This includes any provision of the bilateral agreement except for the Financial Provisions set out under section 4.0. Any such amendment shall be retroactive to the date on which the Emergency Treatment Fund Agreement or the amendment to such an agreement with the other province or territory, as the case may be, comes into force.
10.1 Canada may terminate this Agreement at any time if the terms of this Agreement are not respected by Quebec by giving at least 12 months written notice of its intention to terminate. Quebec may terminate this Agreement at any time if the terms of this Agreement are not respected by Canada by giving at least 12 months written notice of its intention to terminate.
10.2 As of the effective date of termination of this Agreement under section 10.1, Canada shall have no obligation to make any further payments to Quebec.
10.3 As of the effective date of termination of this Agreement under section 10.1, Quebec will repay, on a pro-rated basis, the amounts of federal funds not expended on initiatives set out in Annex A in accordance with the agreed schedule of expenditure, as of the effective date of termination.
10.4 As of the effective date of termination of this Agreement under section 10.1 Quebec agrees to return any federal funding not cost-matched by Quebec consistent with section 4.2.3 and section 4.7.1.
11.1 Any notice, information or document provided for under this Agreement will be effectively given if delivered or sent by letter, postage or other charges prepaid. Any notice that is delivered will have been received on delivery and, except in periods of postal disruption, any notice mailed will be deemed to have been received eight calendar days after being mailed.
The address for notice or communication to Canada shall be:
70 Colombine Drive
Ottawa, Ontario, K1A 0K9
The address for notice or communication to Quebec shall be:
Direction des affaires intergouvernementales et de la cooperation internationale
1005 Chemin Ste-Foy, 1er étage
Québec, Quebec G1S 4N4
12.1 This Agreement, including Annex 1, comprise the entire agreement entered into by the Parties with respect to the subject matter hereof.
12.2 This Agreement shall be interpreted according to the laws of Canada and Quebec.
12.3 No member of the House of Commons, the Senate of Canada or the National Assembly of Quebec shall be admitted to any share or part of this Agreement, or to any benefit arising therefrom.
12.4 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 deemed to be severable and will be deleted from this Agreement, but all the other provisions of this Agreement will continue to be valid and enforceable.
SIGNED on behalf of Canada by the Minister of Health at Ottawa, Ontario this 10 day of August, 2018.
The Honourable Ginette Petitpas Taylor, Minister of Health
SIGNED on behalf of Quebec by the Minister of Health and Social Services at Montreal, Quebec this 21 day of August, 2018.
Gaétan Barrette, Minister of Health and Social Services
SIGNED on behalf of Quebec by the Minister for Rehabilitation, Youth Protection, Public Health and Healthy Living at Quebec, Quebec this 20 day of August, 2018.
Lucie Charlebois, Minister for Rehabilitation, Youth Protection, Public Health and Healthy Living
SIGNED on behalf of Quebec by the Minister responsible for Canadian Relations and the Canadian Francophonie at Quebec, Quebec this 23 day of August, 2018.
Jean-Marc Fournier, Minister responsible for Canadian Relations and the Canadian Francophonie
Annex 1 to the Agreement
Quebec Action Plan
Overview of the opioid overdose crisis in Quebec
Compared to Canada’s western provinces, Quebec remains to date relatively spared from the crisis involving deaths associated with opioid overdoses. However, the situation is already sufficiently concerning that means need to be taken now to deal with it. Based on the most recent dataFootnote 1 for Quebec, analysed by the l’Institut national de santé publique du Québec (INSPQ):Footnote 2
- In 2016, there were 199 deaths attributable to opioid overdoses in Quebec.
- In 2016, the highest number of opioid overdose deaths occurred among persons aged 50 to 59. Persons between the ages of 50 and 64 experienced the most significant increase in the rate of mortality for the period from 2000 to 2014.Footnote 3
- In 2016, deaths attributable to opioid overdoses were distributed as follows in terms of intent: 66% were non-intentional (accidental), 30% were intentional (deliberate) and 4% were of indeterminable intent.
- In 2016, fentanyl or one of its analogues was the cause of 39 of the 199 deaths attributable to an opioid overdose, representing 20% of deaths attributable to this cause in that year.
The data also show that deaths attributable to opioid overdoses are on the rise in Quebec:
- In 2015, data show a 14.4% increase in the number of deaths compared to the average annual rate reported for the 2010-2014 period. The increase is 45% over the annual average for the 2005‑2009 period.
- For the 2010-2014 period, the average annual number of deaths attributable to opioid overdoses rose by 26.8% compared to the number reported for 2005 to 2009.
- The portion of deaths attributable to a fentanyl overdose among those attributable to opioids also increased from an average of 8% annually in the 2010‑2014 period to 14% in 2015.
Funding access to methadone and buprenorphine/naloxone
Two products are used to treat opioid addiction, methadone and buprenorphine/naloxone.
During the 2017 calendar year, the total cost of methadone to Quebec’s public drug insurance plan and its insureds was $7.493M (5,517 people) and $2.965M (1,223 people) for buprenorphine/naloxone. Assuming an annual growth of 5%, the estimated cost for fiscal year 2017‑2018 is $7.587M for methadone and $3.002M for buprenorphine/naloxone, for a total of $10.590M. Below are the forecasts for expenditures for fiscal years 2018‑2019 to 2022‑2023, assuming 5% growth per year.
Total cumulative expenditures for methadone and buprenorphine/naloxone could reach $61.441M for the period from April 1, 2018 to March 31, 2023.
Methadone and buprenorphine/naloxone are already included on the List of Medications of the Basic Prescription Drug Insurance Plan. These medications are therefore covered by both the public health insurance plan and by private group plans. Federal funding will allow continued access to opioid substitute therapy under the public drug insurance plan.
The outcome of this initiative will be measured by the annual number of distinct patients covered by the public drug insurance plan who purchased methadone or buprenorphine/naloxone and the cost to the public drug insurance plan of these two products.
Foster access to wrap‑around services adapted to persons requiring treatment for an opioid‑related problem
One of the targets of the Plan d'action interministériel en dépendence [interministerial action plan on addiction] is to ensure access to opioid addiction treatment across all regions of Quebec. To this end, an additional $6.5M will be allocated annually to integrated health and social services centres with a mission to serve as an addiction rehabilitation centre in order to add stakeholders dedicated to the treatment of opioid addiction.
As part of this project, in addition to the $6.5M already being assumed by the Quebec government annually, we propose to allocate a further $1M from the federal funds in 2018‑2019 and $1.75M annually for the period from 2019‑2020 to 2022‑2023 (for a total of $8M over five years in federal funds). These additional amounts will ensure the quality and accessibility of opioid addiction treatment and encourage outreach work in communities frequented by persons requiring treatment for an opioid‑related problem.
These additional funds will make it possible to implement best practices in the treatment of opioid addiction through skill development by encouraging stakeholders to attend the “Traitement des troubles de l’usage d’opioïdes : une approche de collaboration interdisciplinaire” [treatment of opioid‑related problems: a collaborative interdisciplinary approach] training provided by the Institut national de santé publique du Québec, intended for psychosocial workers, physicians, nurses and pharmacists. The funding will also support the introduction of knowledge transfer activities on relevant topics, such as the best practices guide, to support and provide for the establishment of low‑threshold opioid addiction treatment services. It will also release personnel to participate in these training and knowledge transfer activities.
The additional funds will also be used to develop and implement corridors of care and services to facilitate deployment of outreach services for persons requiring treatment for opioid‑related problems. These corridors of services between addiction rehabilitation centres, family medicine groups (FMG), supervised injection services, homeless shelters and other resources deemed relevant are critical to develop and ensure access to the level of care required by persons needing treatment for an opioid‑related problem.
Significant investments are needed to establish these corridors of services and ensure their continuity.
These funds will be paid to the addiction rehabilitation centre mission of integrated health centres and distributed across Quebec in proportion to the prevalence of opioid use.
- Implementation of best practices in the treatment of opioid addiction through skill development by encouraging the participation of stakeholders in the “Traitement des troubles de l’usage d’opioïdes : une approche de collaboration interdisciplinaire” training of the Institut national de santé publique du Québec, which targets psychosocial professionals, physicians, nurses and pharmacists.
- Participation of stakeholders in knowledge transfer activities on relevant topics, such as the best practices guide, to support and provide for the establishment of low-threshold opioid addiction treatment services.
- Development and implementation of corridors of care and services to facilitate the deployment of outreach services for persons requiring treatment for an opioid‑related problem.
- Ensure access to opioid addiction treatment in all regions of Quebec;
- Improve access to addiction rehabilitation services and reach 4,500 additional people annually.
Facilitating access of stakeholders to “Traitement des troubles de l’usage d’opioïdes : une approche de collaboration interdisciplinaire” training offered by INSPQ
The “Traitement des troubles de l’usage d’opioïdes : une approche de collaboration interdisciplinaire” training developed by the Institut national de santé publique du Québec (INSPQ) is intended for physicians and residents, pharmacists, nurses and psychosocial professionals.
The training provides participants with the tools required to monitor and care for patients who use illegal drugs or who, following a treatment, abuse the use of opioid medication. More specifically, it enhances the knowledge of participants on the phenomenon of dependency on psychoactive substances and its consequences, multidisciplinary care of patients addicted to opioids from a harm reduction perspective, the pharmacology of opioids and the prescription of medication‑assisted treatment, overall assessment of a patient experiencing an opioid‑related problem to determine if the individual is a candidate for medication‑assisted treatment, etc.
Recognized by the Collège des médecins du Québec and the Ordre des pharmaciens du Québec, it optimizes best practices such as interprofessional collaboration, working in networks and outreach. In this regard, it serves as a lever to enhance performance, leadership and the influence of organizations in planning and implementing opioid addiction treatments.
Although this is a measure that has been in place for a number of years and has received annual funding of $60,000 from the Government of Quebec, the purpose of the current project is to expand the provision of this training by facilitating the participation of stakeholders in targeted communities, including addiction rehabilitation centres, family medicine groups (FMG), supervised injection services, community organizations, homeless shelters and other resources deemed relevant. Unlike the previous measure that provided funding to release stakeholders to participate in this training, this action will provide funding to the INSPQ, which is responsible for coordinating the delivery of training. We therefore propose allocating an additional $60,000 per year for the period from 2017‑2018 to 2022‑2023, for a total of $360,000 over six years from federal funds.
The purpose of this project is also to enhance the existing measure through skills development tools to ensure retention of the learning acquired by participants in the “Traitement des troubles de l’usage d’opioïdes : une approche de collaboration interdisciplinaire” training. The project will create and disseminate online vignettes, plan three webinars, and provide post‑training pedagogical support to participants. Annual funding of $45,000 for the period from 2017‑2018 to 2022‑2023 is required for this project, for a total of $225,000 over five years from federal funds.
- Expanded training offering;
- Enhanced skills development tools to ensure training participants retain their learning.
- Number of people who receive training;
- Creation and dissemination of online vignettes;
- Planning of three webinars;
- Post‑training pedagogical support to participants.
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