Health Committee on March 25th, 2010

[The Chair, Conservative, Joy Smith]

Good morning, everybody, and welcome to the health committee.

I'm very pleased to see our wonderful guests today.

Pursuant to Standing Order 108(2), we will do our study on health human resources.

I want to welcome all the witnesses today. We're very involved in our health human resource initiative. Having you come is extremely helpful to us as a committee.

Each of you will have a five-minute presentation, and then we'll go into our Q and A, because I think it is most helpful for the committee to have the opportunity to do that.

We will start with the Aboriginal Nurses Association of Canada, with Rhonda Goodtrack, director of education and secretary-treasurer.

Rhonda, can I have your presentation?

[Rhonda Goodtrack, Director of Education, Secretary-Treasurer, Aboriginal Nurses Association of Canada]

Good morning, and thank you very much for this opportunity.

I'll speak to the briefing note circulated last week. I'll talk to the first three points of our issues on page two.

The first point is improving the science, math, and language skills. Many times the students come to us in the nursing program where they're under-prepared in those areas. At the university level, we have transition programs that help those students be successful in the math, sciences, and English classes. The transition programs are structured with smaller classrooms with extra tutorials. English can be taken over the summer in a more relaxed environment, so that students get the reading and writing skills they need before university starts. Also, the students begin to adapt to university life and expectations. We need to maintain the funding for transition programs and the like.

Funding uncertainty and other constraints are the second point. One of our students is a licensed practical nurse. He wants to get his degree in nursing to become a registered nurse, as he knows there are more opportunities as an RN. He has come to school unable to get a student loan because he and his wife work. He went on maternity leave and took out a line of credit. He works as an LPN and takes full-time nursing classes. You can imagine that he wasn't able to dedicate as much time to those nursing classes as he wanted to.

He recently found out that the funding he was going for under the Métis institution in Saskatchewan wasn't able to fund him in his degree of nursing. He's dropped out, and we don't know if he's going to be coming back to obtain his degree in nursing. This is unfortunate, because he is a much-needed positive role model for our young men.

Another part of the constraints around funding is the definition of what a full-time student is, and the discrepancy between the two individuals I am going to talk about. The university defines a full-time student as someone who has three classes, but post-secondary policies on reserves define it as four classes, so there is a discrepancy. In order to get a full-time living allowance as well as tuition and books, they have to take four classes. There's no question that in nursing the classes are very intensive.

The third point is the systemic support in educational institutions. Equity seats are very important, and where they are implemented, you see a difference. We went from three equity seats in Saskatchewan to 104 in Regina, Saskatoon, and Prince Albert. Currently we have over 200 aboriginal students enrolled in a nursing education program in Saskatchewan, in the undergraduate and graduate programs. As of February 2009, the SRNA, our licensing body, recorded 442 self-identified aboriginal RNs. There are more, but we have a minimum of 442. That number will change in 2010.

It is very important to incorporate aboriginal ways into the nursing curricula. We are serving our people more and more. We are having a greater population base. It is very important to include indigenous knowledge into the curricula, so that we can better serve our communities. We need more aboriginal scholars in the mainstream institutions. The mainstream institutions will be the ones carrying the bulk of educating our people. We need scholarships dedicated to aboriginal students. We need physical symbols that are figured prominently across campus, not just put in someone's office. We need space dedicated for aboriginal people to go to. This builds a sense of community for individuals from remote communities. It also allows them time to be themselves, to take a break from the mainstream.

In those spaces, you will find student advisers who are aboriginal. They can help the students navigate their way through university life and find those resources that will help them become successful. Student ambassadors are used to do community outreach. They are our role models who go to the communities, relate to the students, and share their experiences.

We have pre-health-science summer camps at the U of S. We bring in 20 first nations youth from across the province. They spend two weeks on campus and live the life of a university student. What this does is demystify campus life. It introduces them to staff and faculty and gives them mini-lectures and the like.

That was my five minutes. Thank you, Madam Chair.

[The Chair, Conservative, Joy Smith]

Actually, I gave you a little bit more than that.

[Rhonda Goodtrack]

Probably you did. I figured...

[The Chair, Conservative, Joy Smith]

Your presentation was so good.

[Rhonda Goodtrack]

Thank you so much. I appreciate that.

[The Chair, Conservative, Joy Smith]

We will now go to Dr. Marcia Anderson, past president of the Indigenous Physicians Association of Canada.

[Dr. Marcia Anderson, Past President, Indigenous Physicians Association of Canada]

Thank you for the opportunity to be here today.

The Indigenous Physicians Association of Canada is a voluntary association of first nations, Inuit, and Métis physicians and medical students who hold the vision of healthy and vibrant indigenous nations, communities, families, and individuals, supported by an abundance of well-educated, well-supported indigenous physicians working in partnership with others who share this vision with us.

Since 2004, IPAC has been a leading organization in the development of Canada's medical workforce, through promotion of the recruitment and retention of first nations, Inuit, and Métis medical students and the development of curriculum that will enhance the ability of all of Canada's physicians to deliver high-quality, culturally safe care to first nations, Inuit, and Métis patients.

Our work to date has been in partnership with other organizations such as the Association of Faculties of Medicine of Canada, the Royal College of Physicians and Surgeons of Canada, and national aboriginal organizations. I'm pleased with the progress we have made in developing strong foundational materials for the 17 faculties of medicine to use as they implement recruitment and retention policies and indigenous health curriculum locally. These can be found on our website and include First Nations, Inuit, Métis Health Core Competencies: A Curriculum Framework for Undergraduate Medical Education; IPAC-AFMC Pre-Admissions Support Toolkit for First Nations, Inuit, Métis Students into Medicine; and curriculum modules in family medicine, mental health, and obstetrics and gynecology for use at the post-graduate and continuing medical education levels.

We have celebrated these accomplishments, but much remains to be done. We must keep in mind that it takes a minimum of nine years to train a physician and that the development of the indigenous medical workforce requires increasing the number of students who are graduating from high school, successfully completing the required undergraduate university courses, either identifying or being identified as being qualified to enter medicine, completing medical school, applying to residency, and completing a residency program. While I'm thankful that the aboriginal health human resources initiative has been renewed for two years, I'm concerned that the changes that are still necessary at all levels of learning, which I've just mentioned, are not accomplishable in that timeframe, and that a student who began his or her medical training when AHHRI was first established will not have completed it by the end of the current two-year funding term. Aboriginal health human resources require a long-term commitment and sustained investment in order to achieve its important goals.

Further, as a national professional organization we must maintain our ability to provide leadership in the development of Canada's medical workforce. We are uniquely placed because of our combination of medical training, indigenous health expertise, indigenous community connections, and knowledge of appropriate process to continue to guide our partner organizations and the medical schools as we seek to see curriculum implemented in all 17 schools at all levels of learning, and more students supported to apply and succeed through medical education.

IPAC continues to seek ways in which we can encourage and facilitate this implementation. If supported, we will again be able to have substantial representation at the Canadian Conference on Medical Education, the largest national medical education conference and an excellent chance to meet with deans, administrators, and other indigenous health educators. It was a year ago that Dr. Barry Lavallee, Charlene Hellson, and I presented a plenary session at that conference on cultural safety and indigenous health that provoked tears in multiple attendees and earned us a standing ovation, which had never been done at that conference before.

I mention that because never has it been more apparent, the appetite and the readiness for change that exists when it comes to further developing the indigenous medical workforce. We must continue to push this agenda forward through maintaining the indigenous health educators working group, reviewing the evaluation of projects currently under way and building on the lessons we have learned; developing an indigenous physicians and medical student role model book to inspire our kids and youth; developing courses that will help first nations, Inuit, and Métis students prepare for medical school admission interviews; making progress on the development of a textbook on indigenous health in partnership with the Society of Rural Physicians of Canada, and through nurturing our collaborative relationships with our international indigenous brothers and sisters.

IPAC is privileged to host the Pacific Region Indigenous Doctors Congress in Whistler, B.C., in August 2010. PRIDoC includes representatives from Canada, Australia, New Zealand, United States, Hawaii, Taiwan, and the Pacific Islands. I am the current chair.

PRIDoC will bring to Canada internationally recognized indigenous health researchers, clinicians, and medical educators. There are significant benefits to our students and physicians, and thus to our colleagues and patients. PRIDoC is an excellent time to develop and nurture mentoring relationships; international collaborations in areas of mutual priority such as medical workforce development; knowledge translation; and skill development.

I would not underestimate the importance of peer support for indigenous physicians, given our high workloads, high stress, and resulting high levels of burnout. This is a key retention issue that is often under-addressed.

We have previously applied to Health Canada for support for this important conference through the health care policy contribution program, and we're working with the health human resources strategies division and AHHRI to obtain Health Canada's support. Given the direct relationship of PRIDoC to aboriginal health human resource development, I am hopeful that we will soon hear positive news about Health Canada's support for this high-profile conference.

In closing, on behalf of IPAC I would like to thank the staff at AHHRI in first nations and Inuit health and Health Canada nationally, who have worked with us and supported our leading work in the development of Canada's medical workforce.

We remain committed to improving the medical workforce that serves first nations, Inuit and Métis people by increasing the number of indigenous doctors and better training all physicians to provide high-quality, culturally safe care. We hope we can count on sustained commitment and resourcing until our shared goals are achieved.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much, Doctor, for your very insightful comments. We really appreciate them.

Next we will go to Isabelle Verret, program officer of Aboriginal Health and Human Resources Initiatives. I understand, Isabelle, you have a bit of laryngitis but you're going to persevere and do the best you can.

Thank you.

[Isabelle Verret, Program Officer, Aboriginal Health and Human Resources Initiatives, First Nations of Quebec and Labrador Health and Social Services Commission]

Koey, good morning.

My name is Isabelle Verret, and I am a program officer for Aboriginal Health and Human Resources Initiatives. I am here with my colleague, Michel Deschênes, a policy analyst. We work at the First Nations of Quebec and Labrador Health and Social Services Commission.

We want to thank the Standing Committee on Health for inviting us to give a presentation as part of its discussions on first nations health resources. We hope that your government will take into account first nations realities and that the information we present will serve as a basis for a true partnership, one where Canadian government representatives are on equal footing with first nations political representatives, in an effort to develop policies and implement appropriate measures.

Created in 1994 by the First Nations of Quebec and Labrador Chiefs' Assembly, the commission was intended to help first nations communities and agencies protect, maintain and assert their inherent rights to healthcare and social services, and to help them develop and carry out these programs.

Under the commission's leadership, Quebec's first nations communities established the Quebec First Nations Health and Social Services Blueprint for the period of 2007 to 2017. It represents an important learning process for developing their skills, with a view to asserting their right to manage their programs and services.

In Quebec, 42% of our population is under 25 years of age, and first nations represent nearly 71,000 people. There are 10 nations spread throughout more than 40 communities. It should be noted that almost 70% of our population lives in the communities.

Certain first nations communities live in conditions similar to those in the third world: substandard housing, overcrowding, water problems, outdated schools, underemployment, poverty and so forth. In some communities, the dependency rate on social assistance can reach more than 50%. We can easily see that this difficult environment imposes specific limitations on education in the communities, especially with respect to students dropping out of school.

According to a 2002 study in Quebec communities, more than half of the adults did not have a high school diploma. That proportion is hard to reverse in youth, since half of all young people have already had to repeat a school year.

It is clear that, in order to develop health human resources in Quebec's first nations, they must first receive better access to primary and secondary education, access that it is comparable to that of the rest of the population.

To improve access to basic education, it is first necessary to give schools and communities adequate funding so they can acquire the staff and infrastructure they need to provide appropriate services.

In addition, particular attention should be paid to tailoring teaching methods within and outside the community. To that end, educating aboriginal teachers on first nations culture and society so they can better understand their students would make it easier for students to learn, thereby contributing to a more stimulating academic environment.

Just 3% of first nations students will be able to meet the requirements to access post-secondary education. And those who do manage to overcome the barriers face a number of other factors that make going to school difficult. Some of these factors are as follows: the distance of specialized training institutions in the field of health and social services, which requires students to be away from their families, friends and communities for prolonged periods; the lack of incentives and information regarding health training available in provincial learning institutions; the difficulty related to gaining proficiency in the language of instruction; and the racism endured by aboriginals when they leave their communities.

Furthermore, given the high drop-out rate, a number of students become young adults with families of their own, who must then deal with the obligations of having a family. So not only do they need additional financial assistance, but they also need better access to family housing and daycare. Efforts are needed to tailor extracurricular activities, so these students can have a well-balanced social life, despite being far away from their families and communities.

There is considerably less money spent on recruiting and retaining health professionals, as compared with health institutions in the Quebec network. As a result, Quebec's network is without question more appealing to first nations graduates. What's more, there is little in the way of measures to support health professionals and help them integrate into the communities. Well-established mechanisms should be put in place to address that shortcoming.

In spite of the structural barriers to the development of health resources for first nations, before we wrap up, we would still like to mention a few examples of initiatives and best practices undertaken in Quebec in terms of the recruitment and retention of first nations health professionals and stakeholders.

The Université du Québec à Chicoutimi, UQAC, offers youth intervention training, as well as a program through its faculty of medicine with an aboriginal component. A number of communities have established their own cooperative initiatives with respect to specialized training for their population, such as the human resources training and development centre in Wendake and the Job Education Training Association of Kanawake.

In short, the development of health human resources for first nations is highly complex and requires the involvement of a large number of government and non-government partners in both the education and health sectors. A one size fits all approach cannot be used for all of Canada, as needs vary by region. Solutions must be tailored to the specific reality of each region. That distinction is especially clear in Quebec.

We recommend the following: that the federal government encourage and provide financial support to first nations so they can develop their own health human resources strategy on a regional scale; that, in Quebec, the federal government agree to bring its programs and policies in line with the framework set out in the First Nations Health and Social Services Blueprint for 2007 to 2017; that the federal government foster the creation of post-secondary institutions tailored to first nations, in partnership with colleges, universities and first nations authorities; that the federal government fund training, support and cultural adaptation initiatives to prevent first nations students from dropping out of school for the duration of their academic careers; that the federal government agree to increase funding so that first nations can receive education services comparable to those available to the rest of the population; and that the Aboriginal Health Human Resources Initiative be extended and that the procedural requirements be made clearer and more consistent with the regional needs of first nations.

[The Chair, Conservative, Joy Smith]

Thank you very much. I know you were trying to get through that, so I gave you some extra time.

We will now go to Valorie Whetung, director of the First Nations Centre.

Welcome.

[Valorie Whetung, Director, First Nations Centre, National Aboriginal Health Organization]

Thank you for inviting the National Aboriginal Health Organization here this morning to speak to you. I am here on behalf of Paulette Tremblay, who was unable to come.

I am Ojibway and am a member of the Curve Lake First Nation. As director of the First Nations Centre, I'm responsible for ensuring that we do high quality research that meets the needs of the communities. In fact, tomorrow I'm going to do a health career fair on reserve to speak to students to try to encourage them to enter health careers. That's an issue for us.

We have a young population. As you know from the statistics, half the Inuit population is 22 years and younger, half the first nations population is 25 years and younger, and half the Métis population is 30 years and younger. This compares to a Canadian population that has a median age of 40.

We have a lot of issues in terms of health human resources that need to be addressed to try to correct the health disparities between aboriginal people in Canada and mainstream Canadians. The lack of first nations people in the health care workforce is an issue. Other issues are the recruitment and retention of first nations health care professionals; the need for self-determination in the management of health human resources; and the recognition of the legitimacy of traditional health human resources in the health care system, such as traditional healers, midwives, and elders.

In 2007, NAHO completed a comprehensive survey of the aboriginal health human resource landscape in Canada. We found that there is a general lack of data to identify first nations people in the health care labour force. Where we do have data, we find that the number of first nations people in health care is not nearly equal to the ratio in the population. For example, in Saskatchewan, only 3.7% of health care workers identify as aboriginal, but that population represents 8.5% of the employed population, according to Statistics Canada. The data is limited, but where we have it, we know that there's a disproportionate number of first nations health care professionals.

A possible solution would be to improve access to training possibilities for first nations people who wish to enter health care professions. This may sound simple, but there are barriers to access for first nations that are unique. First, the entrance requirements can be difficult to meet. This is because the completion rate for high school is much lower than it is for the rest of Canadians. For those who do graduate from high school, participation in hard sciences is low. These subjects are necessary to get into the health care professions. More focus on math and science in elementary schools is needed.

It should be noted that per capita funding for first nations students is less than two-thirds of what it is for other Canadian students. In 2008 Jean Charest stated in Le Devoir that spending on the education for first nations children comes to less than half the amount spent on the education of children in non-aboriginal communities.

To encourage first nations people to pursue health careers, it is necessary to invest in early education.

For those who do enter medical training, there is a high dropout rate. Even those who have graduated report that they had to overcome barriers to stay the course. According to the 2006 census, only 240 people who identified as first nations had graduated in medicine, veterinary medicine, or dentistry.

Admission to medical training can be daunting. But paying for it can be even more of a barrier. Because first nations students experience high levels of poverty, funding is an enormous problem, especially when first nations people tend to drop out of high school and then return to higher education as mature students with children. They do not come from wealthy, influential families with a history of medical practitioners and the resources to help them. If they qualify to receive educational assistance from their first nations, the allowance is not enough to live on, so they have to work or get family assistance. Access to student loans is limited for these students if they receive educational assistance from their first nations.

The need for self-determination in the management of health human resources is a critical element in addressing the inequities that exist for first nations people. Clearly, a coordinated effort between first nations governments and health care professional groups will lead to improvements. Research has found that control is a necessary precondition to improvement.

Finally, it's important for first nations that the health care system formally acknowledge the value and legitimacy of traditional health care human resources. The benefits of traditional knowledge and practitioners have been undervalued and maligned by western medicine. It must be remembered that in the not too distant past some of these practices were illegal.

Cultural safety is an ongoing issue, and mainstream health professionals are slowly starting to acknowledge the important contributions of traditional healers, midwives, and elders. It would be advisable to expand the initiatives of the Canadian Institutes of Health Research and the First Nations and Inuit Health Branch to examine the benefits of traditional medicines and cultural practices in health care.

The First Nations Centre supports single parents in health careers with a bursary program. Last year the number of applicants was over 80, but we only had the budget to award five grants. The number of applicants underscores the need to support first nations people wanting to have a career in health.

Now I'd like to speak a bit about the issues that were identified by the Inuit.

Health human resources is a high priority for Inuit. Currently, most health care staff working in Inuit--

[The Chair, Conservative, Joy Smith]

Excuse me, Valorie, do you have a whole lot more? I've given you quite a bit of extra time.

[Valorie Whetung]

Oh, really?

[The Chair, Conservative, Joy Smith]

Yes, really, but you know, we will have questions.

[Valorie Whetung]

Can I just quickly do four points for the Inuit?

[The Chair, Conservative, Joy Smith]

Please. Yes, of course.

[Valorie Whetung]

The four main points for the Inuit were the lack of understanding between providers and parents, high turnover of staff and lack of continuity of care, lack of trust and other issues arising from differences in language and culture, and expensive health care delivery.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you so very much. You'll get an opportunity to fill in some of those things during questions.

We're now going into our first round, with seven minutes... I'm sorry, do we have one more? Yes, we do. Sorry about that.

From the National Indian and Inuit Community Health Representatives Organization we have Debbie Dedam-Montour, executive director. We'd be very pleased to hear from you.

[Debbie Dedam-Montour, Executive Director, National Indian & Inuit Community Health Representatives Organization]

Okay.

Our organization works on behalf of CHRs, community health representatives. CHRs are the front-line, paraprofessional health care providers who have been serving in first nation and Inuit communities for close to 50 years. Many of these communities are remote or isolated. The CHR's tasks encompass health education, health promotion, and disease prevention based on a concept of wellness where the body, mind, spirit, and soul are interconnected. The view of the aboriginal health continuum is about wellness, not illness.

As an organization, we do our utmost to provide an annual national training session promoting holistic health and to build capacity on various issues ranging from diabetes, to prescription drug abuse, to tobacco cessation, to developing resources on sudden infant death syndrome, to HIV/AIDs, to keeping older aboriginal elders active.

The health needs and human resource requirements are about justice and the right to have basic health needs met and the right to fundamental health protections. It is for this reason that I am here to present the health human resource needs and challenges facing CHRs. I will touch on the related issues, such as community and nursing needs.

As far back as 1943, when the then Department of Health and Welfare assumed the responsibility for the health services of Indians, emphasis was put into providing health institutions and into providing professionals to work in these institutions in the remote areas. In 1958 a different approach was taken that led to a primary health care program being initiated in 1962 with 11 CHR pilot sites. The basic element of the program was the training of Indian and Inuit as primary health care workers to enable them to fulfill a role that expanded the health care system. By the time National Indian and Inuit Community Health Representatives Organization was incorporated in 1992, there were an estimated 717 first nation and Inuit CHRs.

In relation to health needs and human resources, it is unreasonable and unjust that first nations are expected to provide an increased and increasing quality and level of community-based health care with funding that does not recognize population growth and current costs over the past 20 years. In addition, the number of CHR positions or associated funding has remained static since 1990, which was the same time as the introduction of the First Nations and Inuit Health Branch's health transfer policy. There was a nursing transformation strategy implemented around the year 2004 that provided one additional nursing position to remote nursing locations only. Everywhere else the number of nursing positions has remained static since the mid-1990s.

When thinking of health human resources from a first nation and Inuit perspective, our list—and I would have to say considering NIICHRO and many of the communities—is doctors when available, nurses when possible, but more importantly, we think of the stable workforce, workers who come from and live in these communities. We think of the community health representatives, a paraprofessional, and how that role has facilitated community development through the introduction of various health programs, such as the national native alcohol drug addiction program, the Canadian prenatal nutrition program, and the aboriginal diabetes initiative.

The CHR scope of duties is very broad. They work with all community members within all stages of life, from promoting good pre-conception health, right up to providing comfort to those in the last stages of their life. They are key in delivering services from a local context, a lifeline in community health. Yet supports for many CHRs are lacking. CHRs and nurses are absolutely necessary in the delivery of core community-based health services, which at the very bare minimum must provide for immunization, TB, and communicable disease control activities.

In preparation for this presentation, I reviewed the 1983-84 CHR program evaluation study. The recommendations from the study are still issues that need to be addressed: financing of CHR training, taking a systematic approach to training, having CHRs as trainers, a method for allocating CHR resources, having advanced training, and having CHR coordinators.

While this evaluation study is dated over 25 years ago, the situation is still the same. The needs of CHRs remain access to training, competitive wages, and defining their scope of practice, as there is such a diversity in that role across the country.

The Royal Commission on Aboriginal Peoples stated that the CHR program is one of the “most successful programs involving Aboriginal people in promoting the health of Aboriginal people”. It further states that, in particular, CHRs “can help Aboriginal individuals and communities learn to exercise personal and collective responsibility with regard to health matters”. One would believe that such statements would set the stage for greater support and capacity development of CHRs.

Sadly, instead of greater support for the program and these important, stable, and trusted front-line paraprofessionals in first nation and Inuit communities, we have in fact seen the CHR program removed from the compendium of programs at the federal level. Other cuts that support the program were made to the CHR national organization, which had operational funding cut in 2000.

Through our initiative called “Road to Competency”, we have developed a list of seven CHR core competencies and 22 sub-competencies. These competencies are to facilitate development of training programs for CHRs. With support from the Assembly of First Nations, we hope to bring this to the regions for consultation that will lead to development of CHR training programs in each region of Canada.

A well-trained community health provider knows their community and has the trust of the population to work together on the modifiable factors to extend life expectancy, that is, lifestyle, diet, exercise, driving safely, reducing misuse and abuse of tobacco, and facilitating access to care. All of these are within the scope of the CHR duties. Thus, they can generate a positive impact, but they need training, ongoing continuing education opportunities, sufficient culturally appropriate resources, and wage parity.

There are some who have stated that the role of CHRs has diminished or that communities are not hiring CHRs. What NIICHRO has noted is that the CHRs are just being retitled; instead of building capacity and increasing the number of these paraprofessional health providers, a variety of new program positions are being created. These new program workers are doing what CHRs have done for almost 50 years.

Working to increase the number of CHRs and their skills capacity is needed now more than ever as we consider the lack of health professionals in this country. For isolated and remote first nation and Inuit communities, this is especially important, as they suffer from periods when there is no nurse, and they only have access to fly-in doctors. The amount of time these health professionals spend in communities is limited and does not provide continuity and opportunity to build trust relationships, both of which would enable better health outcomes.

The major issue is that there needs to be a policy or formula to address how to correct the base funding of health transfer agreements. That funding was based on populations at the time of the health services transfer in the early 1990s.

Support the first nation and Inuit communities with adequate funding to meet their growing population and needs. Support CHR training so that they can evolve to respond to community needs now and in the future.

[The Chair, Conservative, Joy Smith]

Excuse me, Debbie. How much more do you have? I've given you a whole bunch more time.

[Debbie Dedam-Montour]

I have just another couple of lines, if that's okay.

[The Chair, Conservative, Joy Smith]

Okay.

[Debbie Dedam-Montour]

Support CHRs through a policy that supports program delivery through that position, as they are the stable and trusted health care providers.

Invest in the future by increasing human capital. This will lead to health capital. Thus, increasing the number and skills capacity of CHRs will bring better health outcomes.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much.

I've let everyone stretch the time because the presentations were so good.

Debbie, yours was very, very good. Thank you.

We're now going to go into the first round of seven minutes of questions and answers.

We will begin with Dr. Bennett.