Evaluation of Environmental Public Health Services

Background

EPH includes a suite of services that falls under Public Health Promotion and Disease Prevention in ISC's 2023 to 2025 Departmental Results Framework (2023a) and was part of the programs and services brought to Indigenous Services Canada by the First Nations and Inuit Health Branch as a part of departmental transformation in 2017. The objective of EPH services is to identify, assess, mitigate and/or prevent human health risks associated with exposure to hazards and potential risks within the natural and built environments. EPH services are delivered by Environmental Public Health Officers (EPHOs) who are employed by ISC or have been transferred to First Nations communities or Tribal Councils. As of September 2024, 43% of the 144 EPHOs who support communities were transferred. As of December 2024, 311 of 634 First Nations have assumed care and control of their EPH services through health Transfer Agreements.

Evaluation Scope and Methodology

The evaluation covers the period 2015-16 to 2020-21, and was conducted by ISC Evaluation with support from a third-party evaluation firm. The evaluation used a mixed-methods approach that included a review of documents, data and literature; key informant interviews with 15 internal representatives and 7 representatives of transferred services; in-person and remote interviews representatives of 11 communities that receive EPH services from ISC; and, a survey of 50 EPHOs employed by ISC.

Main Findings

Recommendations

1. Ensure that REHMs and EPHOs have access to current and easily transferable knowledge and information they can use and share with community leaders to inform about the overall nature of EPH services and the role of an EPHO.
2. Describe and document the role of an REHM with respect to the level of interaction, engagement and support provided to transferred EPHOs, with the goal of ensuring that a consistent but flexible approach is implemented within and between regions.
3. Identify and implement information management technology that would improve the effectiveness and efficiency of public health data collection, analysis, and use in service planning; and, that would improve the access and use of this data by First Nations.
4. Revisit and update if required the National Framework, to ensure that EPH standards, inspection targets, and methods of prioritization are reasonable and comparable to other jurisdictions in Canada, and if necessary, seek additional EPH resources to ensure those confirmed targets can be met.

Management Response

Environmental Public Health National Office (EPH Division) welcomes this evaluation report and values the opportunity it presents to further improve Environmental Public Health (EPH) service delivery in on-reserve First Nations. While actions will be taken to address the four recommendations in the report, EPH Division will reflect on its totality to further improve EPH Service delivery more broadly. As with all initiatives, EPH Division will work closely with Regional EPH Managers in considering the evaluation findings and addressing the recommendations.

As the evaluation's findings on effectiveness indicate, EPH Services that are vital to community health have been delivered in the context of resource limitations and systemic barriers for many years. Community population growth and infrastructure expansion, alongside climate change and major industrial development, have been key drivers of the expanding gap between what is required for comprehensive EPH Service delivery and what is available. EPH Division has been meeting this pressure to do more with relatively less by developing and implementing strategies with Regional EPH Managers, while EPH Officers work with community leaders to meet the pressure on the ground. Efforts have included the Environmental Public Health Officer (EPHO) Recruitment and Retention Strategy, which is intended to attract more Indigenous people and women to the career and ultimately contribute to efforts to reduce resource gaps and service constraints; the development of a Hazard Prevention Program and accompanying best practices and guidelines for EPH Officers working in communities; risk-based prioritization of service delivery in accordance with the direction of community leaders; and, advocating for consideration of and investment in upstream measures by other sectors that can prevent future EPH hazards and risks. These initiatives are built and rely on the strong relationships pointed to throughout the evaluation report, and will continue alongside activities to address its recommendations.

The recommendations in this report will build further accountability around and advance initiatives that are already underway by EPH Division.

• EPH services is currently using a published resource to introduce the EPH Officer and their role. However, the language is not necessarily accessible to most audiences and is still labelled as a Health Canada resource. The EPH Division is working with communications to improve this resource.
• Transferred EPHOs are considered part of a broad community of practice by FNIHB and are, for example, invited to training events hosted by ISC that contribute to meeting the Canadian Institute of Public Health Inspectors' continuing professional competencies requirements, and to topic-specific webinars. As another example, all written ISC EPH tools and resources are available to transferred EPH Officers. Formalizing the role of Regional EPH Managers in providing this support will ensure predictability for all concerned.
• Activities in support of developing and posting a request for proposals (RFP) for a new digital solution that will improve and modernize EPH data collection and analysis has been slowly moving through the system. Significant milestones have been met, and it is expected that the RFP will soon be published.
• Comparative analysis of EPH Services and their delivery in other Canadian jurisdictions will be required to fully understand whether the National Framework is consistent with standard practices. It is important to note, however, that due to the location, nature and colonization history of First Nations in Canada, in particular those that are remote, isolated, or frequently experience crises, it will be challenging to draw straightforward comparisons and conclusions. The approach taken will be carefully considered and reported on as part of this response.

The involvement of community representatives in this evaluation was invaluable. Community challenges and priorities are central to getting EPH Service delivery right, and as such are the cornerstones to its ongoing relevance and success in preventing and/or mitigating EPH hazards and minimizing risks.

EPH Division looks forward to the further improvement and advancement that will result from addressing these recommendations.

Action Plan Matrix

2.1 History & Context

EPH includes a suite of services that falls under Public Health Promotion and Disease Prevention in ISC's current Departmental Results Framework^{Footnote 1} and was part of the programs and services brought to Indigenous Services Canada by the First Nations and Inuit Health Branch as a part of departmental transformation in 2017. EPH services are delivered in First Nations communities south of the 60th parallel and are meant to comprise comparable services as those delivered off-reserve by public health authorities under public health legislation.

Program documentation provides a history of EPH service delivery, and how these services were delivered in First Nations communities, it goes back to the early 1900's. Prior to the 1900s, many common infectious diseases were thought to be due to bad air or heredity. Scientific discoveries began to transform popular understandings of the transmission and the prevention of infectious diseases, that Individuals and communities could do something to stop the spread of disease and benefit from early detection^{Footnote 2}. First delivered by public health nurses, EPH services have evolved along with our understanding of how to prevent injury, disease and death from risks in natural and built environments. In 1961 the Community Health Representative training program of Indian and Northern Health Services was initiated at Norway House, Manitoba. Students learned how to take water samples, build privies, organize garbage collection, choose suitable sites for wells, and to identify causes and possible prevention of some diseases. By 1967, EPH services were delivered by two "sanitarians" employed by the department (for the entire country). They provided some inspection services in First Nations communities, but the bulk of their time was involved with basic training and education in sanitation matters. The release of the Lalonde report in 1974 resulted in a broader approach to public health. It challenged traditional views about health and led to national and international initiatives in knowledge development, health promotion, and health protection.

Today, EPH services are delivered by Environmental Public Health Officers (EPHOs) who are employed by ISC or have been transferred to First Nations communities or Tribal Councils. As of September 2024, 43% of the 144 EPHOs who support communities are transferred. As of December 2024, 311 of 634 First Nations that have assumed care and control of their EPH services through health Transfer Agreements.

EPHOs carry out services in accordance with the National Framework for EPH services in First Nations Communities South of 60°. Services are coordinated regionally by First Nations and Inuit Health Branch (FNIHB) Regional Offices, and supported nationally by the EPH Division. North of 60°, EPHO-delivered services are the responsibility of Territorial Governments.

EPHOs provide environmental public health services in eight core areas: food safety, housing, public buildings and community facilities inspections, drinking water, wastewater, solid waste disposal, communicable disease control, and emergency preparedness and response. Key activities include public education, training, and EPH assessments (e.g., public health inspections, investigations, monitoring and surveillance), infrastructure plan reviews and, the provision of advice and recommendations.

2.2 EPH Objectives and Expected Outcomes

The objective of EPH services is to identify, assess, mitigate and/or prevent human health risks associated with exposure to hazards within the natural and built environments in First Nations communities south of the 60th parallel. Responsibility to mitigate or address the identified risks is with the community, supported by funding programs where available. As indicated in the EPH logic model in Appendix A, the intended immediate, intermediate, and ultimate outcomes of EPH activities are as follows:

• Immediate Outcomes:
  • First Nations have access to EPH risk identification services;
  • First Nations, Inuit and partners have knowledge of EPH issues, risks, and practices; and,
  • First Nations and the federal government have capacity to engage in the investigation of environmental hazards.
• Intermediate Outcomes:
  • EPH risks are managed in Indigenous communities.
• Ultimate Outcome:
  • Indigenous people and communities are healthier.

2.3 EPH Management, Key Partners and Beneficiaries

The delivery of EPH services supports First Nations communities in identifying and recommending corrective action on potential public health risks that could lead to disease, injury and death.

These services are carried out in First Nations communities south of 60º by EPHOs employed by Indigenous Services Canada, First Nations and Inuit Health Branch or First Nation communities and/or Tribal Councils, in accordance with the National Framework for the EPH services in First Nations Communities South of 60º. Services are coordinated regionally by FNIHB Regional Offices and supported nationally by the EPH Division.

ISC-FNIHB's EPH Division's responsibilities include but are not limited to:

• Supporting Regional EPH activities at the national level;
• Developing national EPH policies and frameworks;
• Updating senior management and central agencies about EPH activities through Departmental Planning Reports, Report on Plans and Priorities, Results-based Management and Accountability Framework (RMAF) reporting and evaluation, and other formal and informal reporting;
• Providing input to Treasury Board submissions and memoranda to Cabinet;
• Analysing data at a national and regional level to support decision-making;
• Developing performance indicators and reporting requirements;
• Providing up-to-date and reliable information about environmental public health issues to Region Offices;
• Identifying environmental public health training gaps and opportunities;
• Liaising with internal and external stakeholders such as national Indigenous organizations and other federal departments and agencies;
• Developing public education materials, including materials for use by EPH Officers;
• Providing technical expertise in environmental areas that may impact public health, such as drinking water quality and treatment, wastewater treatment and disposal, and solid waste disposal;
• Managing direct delivery of the Climate Change and Health Adaptation; First Nations Environmental Contaminants; and Baseline Health and Impact Assessments Programs;
• Delivering health and impact assessment services; and
• Providing analysis services for the EPH services.

ISC-FNIHB Regional Offices responsibilities include but are not limited to:

• Establish and maintain effective working relationships with First Nations communities;
• Providing professional and scientific expertise in the development of public health advisories, recommendations, and the application of mitigation measures;
• Advocating for and promoting compliance with provincial and federal acts, regulations, codes, guidelines and standards by conducting broad-ranging assessments, inspections, surveillance, and evaluations;
• Investigating suspected and confirmed communicable and non-communicable disease incidents and outbreaks, participating in emergency planning (including for human-caused and naturally occurring events);
• Providing expert guidance and professional leadership, in collaboration and cooperation with local, provincial, and federal health authorities;
• Providing professional expertise and guidance, from a public health and an environmental sciences lens, in the development of community emergency response planning, and during response and recovery phases of emergencies;
• Developing and delivering educational materials, workshops, presentations, and formal training across a range of audiences;
• Using and performing calibration on specialized testing equipment to sample/monitor for various chemical, biological, and microbiological components in samples such as air, food, soil, effluent, recreational water, and drinking water;
• Collecting and analyzing data, scientific research and reports, continuously challenging and guiding the measuring and assessments of impacts of mitigation measures from a macro perspective, leading the implementation of prevention and control measures and conducting briefings to senior management and senior community leadership as needed, in collaboration with senior medical, health, and other professionals;
• Liaising with First Nation, federal, provincial, and municipal authorities and private industry using risk communication regarding Environmental Public Health issues;
• Developing annual Regional and Community-level Environmental Public Health Work plans; and
• Working with local health authorities, and provincial departments on cross-jurisdictional public health and environmental public health issues, such as drinking water quality, air quality, and communicable disease issues.

First Nations authorities^{Footnote 3} and communities that receive EPH services from ISC play a central role in EPH programming on-reserve. They work in collaboration with EPHOs to identify environmental public health priorities within their communities and to address environmental public health risks. Their responsibilities include, but are not limited to:

• Engaging and coordinating with Environmental Public Health Services and other stakeholders (e.g., health care workers, ISC-RO, provinces, surrounding municipalities, etc.) to develop, approve, and implement Environmental Public Health community and/or regional work plans;
• Working in partnership with EPHOs, First Nations communities, other health workers, and stakeholders to develop and implement recommendations that relate to environmental public health;
• Providing input from a First Nations perspective when consulted on EPH policies, guidelines, and best practice documents;
• Developing local policies and by-laws to protect and improve the health of the community; and
• Reporting, adhering to Terms and Conditions.

2.4 Program Resources

The following table shows expenditures by type made by the Environmental Public Health subprogram. For the average year shown in the table, EPH expenditures total $44.4 million.

• 53%, or $23.5 million, of average annual expenditures was for ISC personnel including Environmental Public Health Officers and associated O&M.
• 47%, or $20.9 million, of average annual expenditures are transfer or other payments to providers of transferred EPH services.

3.1 Scope and Evaluation Issues

The Evaluation of EPH services covered the traditional subject areas of relevance, effectiveness and efficiency over the period from 2015-16 to 2020-21. The evaluation was carried out from December 2021 to December 2024, with data collection occurring from July 2023 to November 2023. In line with ISC's Five-Year Departmental Evaluation Plan (Indigenous Services Canada 2022a), the evaluation sought to understand progress towards service transfer^{Footnote 5}, as well the cross-cutting issues of Gender-Based Analysis Plus, the impact of climate change, and the impact of COVID-19 on the delivery of EPH services.

Most provinces were included in the scope of the evaluation, apart from British Columbia where EPH programming is the responsibility of the First Nations Health Authority. Similarly, the responsibility for EPH programming in the territories has been transferred to territorial governments or First Nations and Inuit control as part of land-claims settlements.

This was a streamlined evaluation focused on the suite of services delivered to First Nations communities by EPHOs. Other components of EPH programming contained in the EPH Programming Performance Information Profile, including activities and outcomes related to the Climate Change and Health Adaptation Program, Health and Impact Assessment services, First Nations Environmental Contaminants Program, Baseline Assessment Program of health and the Environment, and environmental contaminants research from a total diet and total environment perspective (e.g., the First Nations Food Nutrition and Environment Study), are not included in the scope of the evaluation. The remaining components are being considered as part of the annual ISC five-year evaluation planning cycle, and will be incorporated as appropriate into related evaluations.

Appendix B of this report lists the specific questions and issues that guided the evaluation.

3.2 Lines of Evidence

The evaluation was informed by the following lines of evidence:

• Review of documents and data including previous evaluations, management plans, annual reports and other internal documents.
• Review of published literature related to Indigenous worldviews on lands and land management, and their intersection with health and well-being; environmental public health service trends and pressures; as well as other themes related to these services.
• Key informant interviews, including n=15 with ISC-EPH services representatives including national officials and Regional Environmental Health Managers (REHMs), and n=7 representatives of First Nations-led organizations providing transferred services.
• Interviews and community visits with representatives of 11 communities that receive services through EPH, including n=5 in-community interviews in Saskatchewan (SK, n=3) and Ontario (ON, n=2), and n=6 virtual interviews with community representatives located in Manitoba (MB, n=3), Ontario (ON, n=2), and Quebec (QC n=1).
• Survey of n=50 EPHOs employed by Indigenous Services Canada. This represents a 66% completion rate from among the n=76 EPHOs invited to complete the survey.
  • To the extent possible, the survey design was informed by previous surveys undertaken in 2011 and 2016 to inform past evaluations, to allow for assessment of changes over time.

3.3 Challenges and Limitations

In line with best practices in evaluation (Patton 2002), the following section details the limits and mitigation strategies of the evaluation to provide readers with a sense of the validity and confidence they can have in its findings:

• EPH services are delivered to a vast number of First Nations communities throughout Canada. While efforts were made to obtain feedback from communities across all regions, not all responded to the invitation or declined to participate.
• Many EPH services are delivered by transferred EPHOs. However, the scope and focus of this evaluation is on services delivered by ISC and therefore is not able to report on the totality of EPH services delivered to all First Nations in Canada. To better understand ISC supports for transferred EPH services, the evaluation team held key informant interviews with representatives of First- Nations-led organizations providing transferred services.
• As the evaluation team, including the consulting team at Ference & Company, could not travel to every community or region, a number of mitigation efforts were deployed. These included the survey and virtual interviews with representatives of First Nations-led organizations. However, in-person interviews and virtual interviews may add a layer of complexity in terms of reading non-verbal cues, which could affect the richness of the data. In each interview regardless of location, the evaluation team sought to protect the privacy of interviewees by confirming consent and outlining how participants' data would be stored and used; and has triangulated evidence from the survey, interviews and program data to mitigate the reliability challenges associated with a small sample of respondents.
• The evaluation team, including the consulting team at Ference & Company, did not include any First Nations members and therefore they may not have fully understood the unique cultural perspectives of First Nations in data collection and analysis.
• Progress towards the ultimate outcome of EPH Services was measured, however it is challenging to attribute a causal relationship between long-term changes and immediate activities. EPH Services continues to work to strengthen its performance measurement strategy to ensure accurate and appropriate measures are in place to report on this progress.
• This evaluation covers the period from 2015-16 to 2020-21. Although appropriate at the time the evaluation was launched in 2021, completion was delayed. As a result, ISC will not have the benefit of learnings on the EPH program covering more recent years. In concert with EPH program officials, ISC Evaluation will consider the risk of the limitation and explore opportunities to enhance knowledge of EPH operations through other related evaluations, such as the upcoming evaluation of Water and Wastewater.

4.1 Alignment between EPH services and community needs and priorities

A guiding principle for EPH services is to "work with First Nations communities as active partners" (Health Canada, 2009). As such, EPH services are provided at the request or with the agreement of First Nations authorities. The relationship between EPHOs and the communities they serve tends to be positive and based on mutual respect. This dynamic supports the alignment of service delivery with community need. During several community visits, interviewees described positive professional relationships with EPHOs. Among the n=11 interviewees, n=7 made comments related to the strength of the relationship with the EPHO, or the ways in which they are particularly able to remain attentive to the needs of the community. In some cases, this relationship was the result of a long-standing EPHO and in others it was built through a response to an emergency event. The following is a statement made by a community visit interviewee:

"We work closely with our EHO and he's really supportive. He is always there when we need support, especially when we have a boil water advisory, he provides direction and communicates with Chief and Council, and he provides the reports, recommendation, the letters and all of that." (Community visit interviewee).

Areas of focus for EPHOs and communities comprise of drinking water, inspections of public facilities and housing, food safety, emergency management, communicable disease control, and education and training about EPH risks and mitigation strategies. Among the n=11 community visit interviewees, the following were mentioned as the main activities and services provided by the EPHO to their community: drinking water related activities (n=11); housing inspections (n=8); providing reports, recommendations or advice (n=7); communicable disease related (n=4); animal bite incidents (n=4); support during emergency response (n=4); other facilities inspections (n=3); and food safety training (n=3).

Increased First Nations populations on reserve, infrastructure projects, natural disasters and emergencies and other factors can all increase demand for EPH services according to community visit interviewees and EPHOs. Specifically, among the community visit interviewees (n=7) who discussed operating context, most (n=5) indicated that a growth in population, infrastructure and/or housing units has increased the need for EPH services and a few (n=2) described needs related to information or response to climate/emergency related events. Community visit interviewees were asked if their EPH needs were being met. From among n=11 interviewees, a range of responses were provided, with some providing multiple responses. About half (n=6) indicated that needs are being met, with others (n=6) also indicating that in particular, higher priority concerns and requests for services are acted on quickly by EPHOs; n=5 indicated that they want more frequent visits and more work completed by EPHOs than there appears to be time to do.

The following table shows results to the survey question "To what extent does the current suite of EPH services that you can provide match the needs and priorities of the communities you serve?" Most respondents (76%) indicated either complete or significant alignment. A much smaller number of EPHOs (20%) observed "some alignment".

4.2 Impacts on Diverse Communities

Evaluations of ISC programs and services aim to address the extent to which they account for diverse, intersectional identities of community members, including the needs of youths and Elders. Although there is evidence that the program was designed with diverse populations in mind, primary data collected in this evaluation was not extensive enough to support a comprehensive Gender-Based (Plus) analysis of EPH services.

To illustrate, the Program Information Profile for EPH highlights its focus on specific populations. It notes, for example, that "when prioritizing inspections and when conducting health risk assessments, the populations that use the building is considered. Those locations where specific populations may be found such as infants/children, breastfeeding women, and elders are considered higher risk and prioritized over low-risk locations."

However, when the question of the extent to which EPH supports diverse and intersectional identities was asked to community visit interviewees and internal EPH interviewees, most had no specific response or noted that services are delivered community-wide, and it is difficult to determine how it accounts for population groups specifically. A few internal interviewees (n=3) noted that that by reducing EPH risks, EPH service delivery protects vulnerable populations including both younger and older community members and those with compromised immune systems.

More could be done to direct education and training about EPH risks to diverse audiences such as youth, according to community visit interviewees. Some (n=4) indicated that there was a need for more education and awareness activities directed at youth and/or delivered in schools by EPHOs, and a few (n=2) indicated that greater incorporation of knowledge held by Elders into EPH activities and risk mitigation. The following are related statements made by community visit interviewees.

"More education. Awareness. Spending time in the schools. Bringing in elders into a forum or just talking to them about and getting their feedback too." (Community visit interviewee).

"Maybe there is a missed opportunity for the EPHO to do something at the school, do something like a youth gathering and talk about some of these issues. Maybe he's never been invited to do it. I don't know." (Community visit interviewee).

5.1 Short-term Performance

During the evaluation period, ISC EPHOs carried out an average of about 4,700 inspections of 3,200 unique public facilities annually. While this represented a significant amount of work, the 3 performance indicators that relate to the immediate intended outcome "First Nations have access to environmental public health risk identification services" were not met due to resource limitations. These limitations are discussed further in section 5.4.

The first measure - permanent food facilities are to be inspected at least once annually - aims to achieve a target of 80% annually. The following table shows that inspection rates for permanent food facilities over the evaluation period ranged between 22% (2020-21) and 56% (2015-2016).

The second measure - permanent food facilities with critical violations identified - aims to achieve a target of fewer than 75% with an unsatisfactory result within an inspection category. As shown in the following table, the target was achieved in some years (2015-16, 2019-20, 2020-21) and not in others.

The third performance measure for the immediate intended outcome "First Nations have access to environmental public health risk identification services" is that at least 80% of community care facilities are to be inspected at least once annually. As shown in the following table, the target was not met during the evaluation period with the results ranging between 30% (2020-21) and 59% (2018-2019).

Importantly, the 80% target for the two inspection rates above is actually less than the standard of 100% set out in the National Framework (2009), highlighting that the inspection rate shortfalls for permanent food facilities and community care facilities are more significant than the tables above suggest. Annual, or more frequent, inspection requirements for these types of facilities are typical in other jurisdictions in Canada^{Footnote 7}. Given that a guiding principle for EPH services is to "strive for a level of on-reserve environmental public health services that is comparable to that available off-reserve and consistent from Region to Region" (Health Canada, 2009), there appears to be continued need for improved inspection rates and targets.

Also of note is the sharp decline in the two inspection rates that occurred in 2020-21, which will be discussed in a later section dedicated to the impacts on EPH of the COVID-19 pandemic.

Moving to the second immediate intended outcome: "First Nations, Inuit and partners have knowledge of potential EPH hazards, risks, and mitigation practices". The target is that 100% of communities have access to trained Community Based-Water Monitors or EPHOs to monitor drinking water quality. This target has been has met and maintained over the evaluation period. All (100%) communities had ongoing access to trained Community-Based Water Monitors or EPHOs to monitor drinking water^{Footnote 8}.

5.2 Achievement of intermediate and ultimate results

For the intermediate intended outcome: "EPH risks are managed in Indigenous communities" EPH has met but not maintained the related performance target. According to the performance targets, public water systems in First Nations communities are to be monitored for bacteria at a rate of 82% of the recommended number of sampling weeks. As shown in the following table, the target was achieved in 2017-18 (85%) and 2019-20 (83%). The COVID-19 pandemic had a significant impact on both normal, planned, and periodic drinking water activities due to restricted access to communities, which coincided with reduced overall sampling rates in 2020-21 to 70%.

The ultimate intended outcome of EPH services is that Indigenous people and communities are healthier, which is measured using two indicators. The first is the number of confirmed water/foodborne disease outbreaks Both the baseline (2019-20) and ongoing targets are zero (i.e., no outbreaks), and data are captured by Regional Environmental Health Managers through the Performance Indicator Questionnaire that is provided to the National Office on a yearly basis. As there were no outbreaks during the evaluated period, this target is deemed met, though it is important to acknowledge that factors beyond EPH activities impact the result of this indicator, and that zero incidence does not imply zero risk. The second indicator is the percentage of First Nations and Inuit adults who reported being in excellent or very good health. The baseline rate of 37.8% is derived from the most recent available data from the First Nations Regional Health Survey (2015-16). Progress towards the target (44% by March 2028) is expected to be measured using data from future survey cycles.

5.3 Achievement of EPH Inspection Rate Standards

In addition to the inspection rates that are measured as part of EPH's performance indicators, the National Framework (2009) indicates that a range of public facilities, including health, community care, general, and recreational are to be inspected between 1-4 times per year^{Footnote 9}.

The following table shows inspection rates by type of public facilities on reserve, ordered by a simple average of yearly inspection rates from high to low. From this data it is evident that inspection standards were generally not met, as no type of facility approached 100% inspection rates in any year of the evaluation period. Coinciding with the immediate performance indicators discussed above, community care and permanent food facilities – already covered in section 5.1 but included here again for comparison – had the highest overall inspection rates relative to other types of facilities.

EPH has been operating under these conditions for many years, with each EPH annual report during the evaluation period raising the issue of resource constraints and inspection rates that fall below standard. In this context, to maximize effectiveness in terms of preventing adverse health events, EPHOs prioritized their tasks based on inherent risk of activities being carried out at a given location, emergency events such as fires and floods, and community requests. This was highlighted by internal key informants, the majority (75% - 90%) of whom indicated that emergency events and community requests can be prioritized ahead of other work such as routine inspections of lower-risk facilities.

5.4 Delivery Challenges

Workload analysis and other data, such as the inspection rate deficiencies noted above, consistently show that the number of EPHOs is inadequate to fully meet objectives. For example, an internal workload analysis projected a shortfall of 35 EPHOs to meet EPH's 2020-21 targets for inspections, advice and guidance, monitoring, public education, and drinking water activities (Indigenous Services Canada 2021). ISC EPH Activities in First Nations Communities on Reserve Annual Reports make consistent reference to resource constraints throughout the evaluation period, and community representatives in this evaluation indicate that they want more from their EPHOs. For example, from among n=11 community visit interviews, n=5 indicated that they want more frequent visits, and more work completed by their EPHO.

Based on the evaluation findings, it is recommended that ISC:

1. Ensure that REHMs and EPHOs have access to current and easily transferable knowledge and information they can use and share with community leaders to inform about the overall nature of EPH services and the role of an EPHO. (Supported by Findings #1 and #3)
2. Describe and document the role of an REHM with respect to the level of interaction, engagement and support provided to transferred EPHOs, with the goal of ensuring that a consistent but flexible approach is implemented within and between regions. (Supported by Finding #4)
3. Identify and implement information management technology that would improve the effectiveness and efficiency of public health data collection, analysis, and use in service planning; and, that would improve the access and use of this data by First Nations. (Supported by Findings #1 and #3)
4. Revisit and update if required the National Framework, to ensure that EPH standards, inspection targets, and methods of prioritization are reasonable and comparable to other jurisdictions in Canada, and if necessary, seek additional EPH resources to ensure those confirmed targets can be met. (Supported by Findings #1, #2 and #5)

EPH Output or outcome

Relevance:

1. To what extent do these services address continued and emerging needs?
2. How has the context within which the services are delivered changed over the evaluation period?

Effectiveness:

3. To what extent have expected results been achieved?
4. How has service delivery contributed to the achievement of departmental objectives and outcomes?

Efficiency:

5. To what extent are the services delivered in an efficient manner?
6. How appropriate are the current divisions of roles and responsibilities within and between: national office/EPH Division, Regional offices, delivery partners, and recipients?

Service Transfer

7. How might the delivery of EPH services be improved and/or structured to advance service transfer to First Nations partners?
8. If service transfer was to happen in your region, what would be necessary to make this feasible; how can the Department better support this transfer?

Cross-Cutting Issues

9. How is climate change impacting EPH services and its outcomes/operations?
10. How has the design of the EPH services considered: the diverse and intersectional identities of its recipients; and its impacts on youth and elders?
11. How has the COVID-19 pandemic effected EPH services (e.g. key challenges, positive or negative effects on planned activities)? What are the main challenges?