Non-Insured Health Benefits program: First Nations and Inuit Health Branch: Annual report 2020 to 2021

Introduction

The Non-Insured Health Benefits (NIHB) program provides registered First Nations and recognized Inuit with coverage for a range of medically necessary health benefits including prescription drugs and over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment (MS&E), mental health counselling, and transportation to access medically required health services that are not available on reserve or in the community of residence. This report covers the 2020 to 2021 fiscal year. A fiscal year runs from April 1 to March 31. During 2020 to 2021, NIHB provided access to benefits coverage to 898,839 eligible clients.

In line with Canada's commitments under the United Nations Declaration of the Rights of Indigenous Peoples and the Truth and Reconciliation Commission's Calls to Action, Indigenous Services Canada (ISC) works with Indigenous organizations including the Assembly of First Nations and the Inuit Tapiriit Kanatami, to advance shared priorities focused on improving and closing the gaps in health outcomes for Indigenous Peoples.

Now in its twenty-seventh edition, the 2020 to 2021 NIHB Annual Report provides national and regional data on the NIHB program client population, expenditures, benefit types and benefit utilization. This Report is published in accordance with the NIHB program's performance management responsibilities and is intended for the following target audiences:

• First Nations and Inuit organizations and governments at community, regional and national levels
• Regional and Headquarters managers and staff of Indigenous Services Canada and
• Others in government and in non-government organizations with an interest in the provision of health services to First Nations and Inuit communities.

British Columbia Tripartite Agreement

The British Columbia Tripartite Framework Agreement on First Nation Health Governance was signed by Canada, the First Nations Health Council (FNHC) and the British Columbia Ministry of Health on October 13, 2011. Consistent with the commitments set out in the Framework agreement, between July 2, 2013 and October 1, 2013 the First Nations Health Authority (FNHA) assumed responsibility for the design, management, delivery and/or the funding of the delivery of health services to First Nations residing in British Columbia. Since that time, First Nations individuals residing in BC have received their health benefits through the FNHA's Health Benefits Program, which replaced the NIHB program in BC.

Figure 2.1: Eligible client population by region: March 2021

The Ontario region had the largest proportion of the eligible population, representing 24.3% of the national total, followed by the Manitoba Region at 17.9% and the Saskatchewan region at 17.7%

Note that population values are based on region of band registration, which is not necessarily the client's current region of residence. The majority of British Columbia clients previously covered by the NIHB program are now covered by the B.C. First Nations Health Authority (FNHA) and are not represented in this chart. The remaining NIHB clients in B.C. are Inuit clients, or clients associated with B.C. bands, but residing in other provinces and territories of Canada, where they are covered under the NIHB program.

Source: SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Figure 2.1: Eligible client population by region: March 2021

This image is a map of Canada with the following population values:

• Atlantic has 66,782
• Quebec has 76,085
• Ontario has 218,784
• Manitoba has 160,954
• Saskatchewan has 158,785
• Alberta has 128,230
• British Columbia has 17,019
• Yukon has 7,742
• Northwest Territories have 27,847
• Nunavut has 36,611
• Total eligible population is 898,839

Table 2.1: Eligible population by client type and region: March 2020 and March 2021

Of the 898,839 total eligible clients at the end of the 2020 to 2021 fiscal year, 848,247 (94.4%) were First Nations clients while 50,592 (5.6%) were Inuit clients. The number of First Nations clients increased by 1.2% and the number of Inuit clients increased by 1.8%.

From March 2020 to March 2021, British Columbia had the highest percentage change in total eligible clients with a 2.8% increase, followed by Quebec and the Atlantic region with increases of 2.3% and 2.2% respectively.

Chart 2.1: Eligible client population over time: March 2012 to March 2021

Over the past 10 years, the total number of eligible clients in the SVS has increased by 0.2%, from 896,624 in March 2012 to 898,839 in March 2021.

The NIHB program client population was significantly impacted during this period by amendments to the Indian Act affecting client eligibility and by the creation of the FNHA in British Columbia, which resulted in approximately 133,430 clients in B.C. being removed from the NIHB client population when they became eligible to receive benefits through the FNHA.

Source: SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 2.1: Eligible client population, March 2012 to March 2021

This image visually describes NIHB eligible population growth over ten years as follows:

• 2012 was 896,624
• 2013 was 926,044
• 2014 was 808,686
• 2015 was 824,033
• 2016 was 839,129
• 2017 was 853,088
• 2018 was 867,749
• 2019 was 873,312
• 2020 was 887,518
• 2021 was 898,839

Over the past five years, the NIHB program's total number of eligible clients increased by 5.4% from 853,088 in March 2017 to 898,839 in March 2021. Quebec had the largest increase in eligible clients over this period, with a growth rate of 7.3%. Saskatchewan and Nunavut followed with growth rates of 6.6% and 6.0% respectively.

Chart 2.2: Annual population growth, Canadian population and eligible client population: 2012 to 2021

From 2012 to 2021, the Canadian population increased by 10.6% while the NIHB eligible First Nations and Inuit client population increased by 0.2%. Factoring out the impact of the removal of FNHA clients, the NIHB ten year eligible population increase was 17.8%, with an average annual growth of 1.7%.

The higher than average NIHB program client population growth rate of 6.0% in 2012 and 3.3% in 2013 can be attributed to the registration of clients newly eligible under Bill C-3, and to new Qalipu Mi'kmaq First Nations clients in the Atlantic Region.

Source: SVS and Statistics Canada Catalogue No. 91-002-XWE, Quarterly Demographic Statistics, adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 2.2: Annual population growth, Canadian population and eligible client population: 2012 to 2021

This image is a line graph that visually describes annual population growth for the NIHB eligible population and for the Canadian population.

Year	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021
NIHB client Population	896,624	926,044	808,686	824,033	839,129	853,088	867,749	873,312	887,518	898,839
Growth rate	6.0%	3.3%	-12.7%	1.9%	1.8%	1.7%	1.7%	0.6%	1.6%	1.3%
Canadian population	34,349,236	34,754,312	35,152,370	35,535,348	35,832,513	36,264,604	36,708,083	37,058,856	37,589,262	38,005,238
Growth rate	1.0%	1.2%	1.2%	1.1%	0.8%	1.2%	1.2%	1.0%	1.4%	1.1%

Table 2.3: Eligible client population by age group, gender and region: March 2021

Of the 898,839 NIHB eligible clients on the SVS as of March 31, 2021 49.2% were male (442,332) and 50.8% were female (456,507).

The average age of the eligible client population was 34 years of age. By region, this average ranged from a low of 28 years of age in Nunavut to a high of 41 years of age in British Columbia.

The average age of the male and female eligible client population was 33 years and 35 years respectively. The average age for males ranged from a low of 27 years in Nunavut to a high of 39 years in British Columbia. The average age for females varied from a low of 28 years in Nunavut to a high of 43 years in British Columbia.

The NIHB eligible client population is relatively young with nearly two-thirds (62.5%) under the age of 40. Of the total population, almost one-third (29.9%) are under the age of 20.

The senior population, defined as clients 65 years of age and over, has been slowly increasing as a proportion of the total NIHB client population. In 2012, seniors represented 6.6% of the overall NIHB population. Most recently in 2021, seniors accounted for 9.4%.

Population analysis by age group: March 2021

The overall NIHB client population is relatively young compared to the general Canadian population. The share of the NIHB client population under 20 years of age was 29.9% compared to 21.4% for the Canadian population. The average age of NIHB clients is 34 compared to 42 years of age for the Canadian population.

Chart 2.3: Proportion of Canadian population and of the First Nations and Inuit (FN&I) client population, by age group

Source: SVS and Statistics Canada CANSIM table 051-0001, Population by Age and Sex Group, adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 2.3: Proportion of Canadian population and of the First Nations and Inuit (FN&I) client population, by age group

This image is a bar graph that visually describes the proportion of the Canadian population and the NIHB eligible population by age group, as follows:

• the percentage of the Canadian population aged 0 to 9 is 10.4%
• the percentage of the NIHB population aged 0 to 9 is 12.2%
• the percentage of the Canadian population aged 10 to 19 is 11.0%
• the percentage of the NIHB population aged 10 to 19 is 17.7%
• the percentage of the Canadian population aged 20 to 29 is 13.5%
• the percentage of the NIHB population aged 20 to 29 is 17.6%
• the percentage of the Canadian population aged 30 to 39 is 13.9%
• the percentage of the NIHB population aged 30 to 39 is 15.1%
• the percentage of the Canadian population aged 40 to 49 is 12.8%
• the percentage of the NIHB population aged 40 to 49 is 11.9%
• the percentage of the Canadian population aged 50 to 59 is 13.7%
• the percentage of the NIHB population aged 50 to 59 is 11.5%
• the percentage of the Canadian population aged 60 and over is 24.7%
• the percentage of the NIHB population aged 60 and over is 14.0%

A comparison of March 2017 to March 2021 eligible client population shows an aging population. The client population 40 and above, as a proportional share of the overall client population, increased from 35.2% in 2017 to 37.5% in 2021.

Chart 2.4: Proportion of Eligible First Nations and Inuit Client Population by Age Group

Source: SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 2.4: Proportion of Eligible First Nations and Inuit Client Population by Age Group

This image is a bar graph that visually describes the proportion of First Nations population and of Inuit population by age group as follows:

• the proportion of the First Nations and Inuit population aged 0 to 9 was 15.3% in March 2017 and 12.2% in March 2021
• the proportion of the First Nations and Inuit population aged 10 to 19 was 17.6% in March 2017 and 17.7% in March 2021
• the proportion of the First Nations and Inuit population aged 20 to 29 was 18.1% in March 2017 and 17.6% in March 2021
• the proportion of the First Nations and Inuit population aged 30 to 39 was 13.9% in March 2017 and 15.1% in March 2021
• the proportion of the First Nations and Inuit population aged 40 to 49 was 12.3% in March 2017 and 11.9% in March 2021
• the proportion of the First Nations and Inuit population aged 50 to 59 was 11.2% in March 2017 and 11.5% in March 2021
• the proportion of the First Nations and Inuit population aged 60 and over was 11.7% in March 2017 and 14.0% in March 2021

NIHB program sustainability: 2020 to 2021

Cost and service pressures on the Canadian health system have been linked to factors such as an aging population and the increased demand for and utilization of health goods, particularly pharmaceuticals, and services. In addition to these factors, NIHB program expenditures are driven by the number of eligible clients and their medical needs. The NIHB client population is growing at approximately two times the Canadian population growth rate. A significant proportion of NIHB clients live in small and remote communities, and require medical transportation to access health services that are not available locally.

Chart 3.1: NIHB expenditures by benefit ($ millions): 2020 to 2021

In 2020 to 2021, total NIHB program benefit expenditures were $1,490.6 million. This represents a decrease of 1.9% over NIHB expenditures of $1,519.5 million in 2019 to 2020. Of the 2020 to 2021 total, Pharmacy benefit costs represented the largest proportion at 37.0% of expenditures ($550.9 million), followed by Medical Transportation costs at 35.3% ($525.7 million) and Dental benefit costs at 15.9% ($236.3 million).

NIHB Pharmacy, Dental and Medical Transportation benefit expenditures accounted for 88.1% of NIHB expenditures in 2020 to 2021.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 3.1: NIHB expenditures by benefit ($ millions): 2020 to 2021

This image is a pie chart visually describing NIHB expenditures in millions and proportion of total by benefit area for fiscal year 2020 to 2021, as follows.

• total expenditure for medical transportation is $525.7 and proportion of total expenditures is 35.3%
• total expenditure for pharmacy is $550.9 and proportion of total expenditures is 37.0%
• total expenditure for dental is $236.3 and proportion of total expenditures is 15.9%
• total expenditure for medical supplies and equipment is $51.5 and proportion of total expenditures is 3.5%
• total expenditure for mental health care are $74.0 and proportion of total expenditures is 5.0%
• total expenditure for vision care is $46.0 and proportion of total expenditures is 3.0%
• total expenditure for other is $12.3 and proportion of total expenditures is 0.8%

Not reflected in the $1,490.6 million in NIHB expenditures are approximately $73.4 million in administration costs. More detail is provided in Section 10.

Table 3.1: NIHB expenditures and growth by benefit: 2020 to 2021

NIHB program benefit expenditures decreased by 1.9%, or $28.9 million from fiscal year 2019 to 2020, due in large part to the effects of the coronavirus (COVID-19) outbreak. Certain NIHB benefit areas had a decrease in expenditures over the previous fiscal year because of provincial/territorial public health restrictions on travel and on the provision of in-person services. The highest net increase in expenditures over fiscal year 2019 to 2020 were in the NIHB pharmacy and mental health benefits at $18.9 and $18.8 million respectively. The NIHB Dental benefit saw the largest decrease at $46.6 million. Factors affecting benefit expenditure growth are discussed in subsequent sections of this report.

* Expenditures in the "other" category are related to program oversight, including funding arrangements with the FNHA for clients eligible under Bills C-3, S-3, and Qalipu clients, as well as contribution agreements with Indigenous partner organizations.

Table 3.2: NIHB expenditures by benefit and region ($ 000's): 2020 to 2021

Manitoba accounted for the highest proportion of total expenditures at $338.0 million, or 22.7% of the national total, followed by Saskatchewan at $286.0 million (19.2%), and Ontario at $274.0 million (18.4%). By comparison, the lowest expenditures were in the Atlantic region at $74.0 million (5.0%).

Headquarters expenditures by benefit type represent costs paid for claims processing services. Headquarters expenditures in the other category are comprised of operational expenditures associated with the program oversight and policy development of the NIHB Program, include funding arrangements with the FNHA for clients eligible under Bills C-3 and S-3, and Qalipu clients, as well as with national client partner organizations, such as the Assembly of First Nations and Inuit Tapiriit Kanatami, and regional Indigenous organizations. Headquarters expenditures account for 1.9% ($28.1 million) of total NIHB expenditures, and do not include the $73.4 million in headquarters administrative costs outlined in Section 10.

Table 3.3: Proportion of NIHB expenditures by region: 2020 to 2021

In 2020 to 2021, Manitoba had the highest proportion of total NIHB expenditures (22.7%) and accounted for 29.6% of total NIHB Medical Transportation expenditures. This can be attributed to the large number of First Nations clients living in remote or fly-in only northern communities in the Manitoba region.

Saskatchewan had the highest proportion of NIHB Pharmacy expenditures at 21.1%, followed by Manitoba and Ontario at 19.4% and 19.1% respectively.

Alberta, which accounted for 15.0% of total NIHB expenditures in 2020 to 2021, recorded the highest proportion of total NIHB Dental expenditures at 20.2%, followed by Saskatchewan and Ontario at 20.1% and 20.0% respectively.

The proportion of NIHB Vision Care expenditures was highest in Saskatchewan at 21.3%, followed by 20.1% in Alberta and 18.4% in Ontario.

Table 3.4: Proportion of NIHB regional expenditures by benefit: 2020 to 2021

At the national level, nearly three-quarters (72.2%) of total program expenditures occurred in two benefit areas: pharmacy (37.0%) and medical transportation (35.3%). Dental expenditures accounted for almost one-fifth (15.9%) of total NIHB expenditures.

Medical transportation expenditures accounted for half of benefit expenditures in the Northern region and Manitoba (61.0% and 46.1%, respectively). Conversely, in the Atlantic region only 17.9% of benefit expenditures were spent on medical transportation.

The proportion of dental expenditures ranged from 12.8% in Manitoba to 21.4% in Alberta.

In the Atlantic region, 50.4% of total expenditures were spent on pharmacy benefits. Pharmacy costs represented the highest percentage of total expenditures in all regions except in the Northern region and in Manitoba, where transportation accounted for the largest share of costs.

Chart 3.2: NIHB annual expenditures ($ millions) and percentage change

In 2020 to 2021, NIHB program expenditures totalled $1,490.6 million, a decrease of 1.9% from $1,519.5 million in 2019 to 2020. Since 2011 to 2012, total expenditures have grown by 38.8%. The annualized rate of growth over this period was 3.8%. There has been wide variation in growth rates between 2011 to 2012 and 2020 to 2021, from a low of -7.1% in 2013 to 2014* to a high of 9.7% in 2016 to 2017.

Fluctuations in NIHB expenditures growth rates are impacted by a number of factors as set out in figure 3.1. Changes in the eligible client population have a direct impact on growth. Notable examples include the transfer of responsibility for First Nations clients residing in B.C. to the FNHA in 2013 to 2014, the creation of the Qalipu Mi'kmaq band in 2011, and an increase in eligible clients as a result of amendments to the Indian Act.

*If expenditures for FNHA eligible clients are excluded from 2012 to 2013 and 2013 to 2014 total NIHB expenditures, then the growth rate for 2013 to 2014 would have been 2.8%.

Source: FIRMS and FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 3.2: NIHB annual expenditures ($ millions) and percentage change

This image is a bar graph which visually describes NIHB annual expenditures in millions and annual percentage change by fiscal year, as follows:

• 2011 to 2012 is $1,074 and 4.5%
• 2012 to 2013 is $1,105 and 2.8%
• 2013 to 2014 is $1,026 and -7.1%
• 2014 to 2015 is $1,031 and 0.5%
• 2015 to 2016 is $1,101 and 6.7%
• 2016 to 2017 is $1,207 and 9.7%
• 2017 to 2018 is $1,309 and 8.4%
• 2018 to 2019 is $1,391 and 6.2%
• 2019 to 2020 is $1,519 and 9.3%
• 2020 to 2021 is $1,491 and -1.9%

Table 3.5: NIHB annual expenditures by benefit ($ 000's)

In the 10 year period ending 2020 to 2021, expenditures for NIHB mental health services and medical transportation benefits have grown more than other benefit areas. NIHB mental health expenditures had the highest percentage growth at 471.7%, from $12.9 million in 2011 to 2012 to $74.0 million in 2020 to 2021. NIHB medical transportation had the highest expenditure growth from $333.3 million in 2011 to 2012 to $525.7 million in 2020 to 2021, a change of 57.7%.

Over the same period, NIHB medical supplies and equipment (MS&E) expenditures increased by 67.1% and NIHB pharmacy expenditures increased by 28.6%.

The Other expenditure category includes funding arrangements with regional First Nations and Inuit organizations that employ NIHB Navigators to act as a resource for communities, organizations or individuals who need assistance or information on the NIHB program. As well, it includes funding arrangements with the First Nations Health Authority for clients eligible under Bills C-3 and S-3 and for Qalipu clients. Decreases in other expenditures in 2013 to 2014 can be attributed to the transfer of responsibility for provincial health care insurance premiums for First Nations clients residing in British Columbia to the FNHA in 2013.

Chart 3.3: Per capita NIHB expenditures by region: 2020 to 2021

The national per capita expenditures for all benefits in 2020 to 2021 were $1,627. The Northern region had the highest per capita cost at $2,184. Manitoba followed with a per capita cost of $2,100. The higher than average per capita cost for these regions is partly attributable to high medical transportation costs due to the large number of First Nations and Inuit clients living in remote or fly-in only northern communities. By contrast, the Atlantic region had the lowest per capita cost of $1,108, due to the comparatively low medical transportation expenditures in the region.

Source: FST and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 3.3: Per capita NIHB expenditures by region: 2020 to 2021

This bar graph visually describes NIHB annual expenditures in millions by fiscal year and by region. Per capita expenditures:

• for Atlantic are $1,108
• for Quebec are $1,364
• for Ontario are $1,252
• for Manitoba are $2,100
• for Saskatchewan are $1,801
• for Alberta are $1,739 and
• for the North are $2,184
• national per capita expenditures are $1,627

Chart 4.1: Distribution of NIHB pharmacy expenditures ($ millions): 2020 to 2021

The NIHB pharmacy benefit is comprised of multiple components. Prescription drugs paid through the Health Information and Claims Processing Services (HICPS) system was the largest piece, accounting for $432.8 million or 78.6% of all NIHB pharmacy expenditures, followed by over-the-counter (OTC) drugs and controlled access drugs (CAD) which totalled $90.0 million or 16.3%.

Regional Drugs, at $1.8 million or 0.3% of pharmacy benefit costs, refers to prescription drugs and OTC medications paid through Indigenous Services Canada regional offices.

Contribution agreements, which accounted for $12.1 million or 2.2% of total pharmacy benefit costs, are used to fund the provision of pharmacy benefits through agreements such as those with the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Other costs totalled $14.2 million or 2.6% in 2020 to 2021. Included in this total are headquarters contract and claims processing expenditures related to the HICPS system.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 4.1: Distribution of NIHB pharmacy expenditures ($ millions): 2020 to 2021

This image is a pie chart which visually describes NIHB pharmacy expenditures in millions and proportion of total expenditures by component type:

• prescription drugs (HICPS) are $432.8 and 78.6%
• OTC/CAD drugs (HICPS) are $90.0 and 16.3%
• other costs are $14.2 and 2.6%
• contribution agreements are $10.1 and 1.7%
• regional drugs are $1.8 and 0.3%
• total expenditures $550.9

Table 4.1: Total NIHB pharmacy expenditures by type and region ($ 000's): 2020 to 2021

Prescription drug costs paid through the HICPS system represented the largest component of total NIHB Pharmacy costs accounting for $432.8 million or 78.6%. The Saskatchewan region had the largest proportion of these costs at 21.1%, followed by Manitoba at 19.4% and Ontario at 19.1%.

The next highest component was over-the-counter (OTC) and controlled access drug (CAD) costs at $90.0 million or 16.4%. The regions of Manitoba (23.5%), Saskatchewan (20.8%) and Ontario (17.8%) had the largest proportions of these costs in 2020 to 2021.

Annual NIHB pharmacy expenditures

NIHB pharmacy expenditures increased by 7.9% during fiscal year 2020 to 2021. Over the past five years, growth in pharmacy expenditures has ranged from a high of 8.3% in 2019 to 2020 to a low of 1.0% in 2018 to 2019.

The five year annualized growth rate for NIHB pharmacy expenditures is 4.5%. The introduction of lower cost generic drugs as they become available on the market and optimized drug utilization have kept pharmacy benefit growth moderate. As well, NIHB has negotiated Product Listing Agreements (PLA) with drug manufacturers to allow for the coverage of certain medications at a reduced price through the use of rebates, medications which would otherwise not be considered cost-effective or affordable. On March 31, 2021, NIHB had 224 PLA in effect.

Chart 4.2: Annual NIHB pharmacy expenditures and percentage change

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 4.2: Annual NIHB pharmacy expenditures and percentage change

This image is a bar graph which visually describes NIHB annual pharmacy expenditures in millions and percentage change by fiscal year, as follows:

• 2016 to 2017 are $441.2 and 7.8%
• 2017 to 2018 are $467.1 and 5.9%
• 2018 to 2019 are $471.6 and 1.0%
• 2019 to 2020 are $510.7 and 8.3%
• 2020 to 2021 are $550.9 and 7.9%

Chart 4.3: Per capita NIHB pharmacy expenditures by region: 2020 to 2021

In 2020 to 2021, the national per capita expenditure for NIHB Pharmacy benefits was $597. This was an increase of 3.8% from the $575 recorded in 2019 to 2020.

Saskatchewan had the highest per capita NIHB Pharmacy expenditures at $732, followed by Quebec at $700.

The Northern region had the lowest per capita expenditures at $408 followed by Ontario at $481. Relatively low per capita expenditures in the North are attributed to lower than average utilization rates and also a younger population utilizing lower cost medications.

Source: FST and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 4.3: Per capita NIHB pharmacy expenditures by region: 2020 to 2021

This image is a bar graph which visually describes NIHB pharmacy expenditures per capita by region, as follows:

• Atlantic is $559
• Quebec is $700
• Ontario is $481
• Manitoba is $664
• Saskatchewan is $732
• Alberta is $662
• North is $408 and
• National is $597

Chart 4.4: NIHB pharmacy operating expenditures per claimant by region: 2020 to 2021

Expenditures per claimant are based on the total cost of pharmacy claims processed through the HICPS system, divided by the number of clients who submitted at least one pharmacy claim.

In 2020 to 2021, the national average per claimant expenditures were $1,028.

The Quebec Region had the highest average NIHB Pharmacy operating expenditures per claimant at $1,204, followed by Saskatchewan at $1,142.

Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 4.4: NIHB pharmacy operating expenditures per claimant by region: 2020 to 2021

This image is a bar graph which visually describes NIHB annual pharmacy operating expenditures per claimant by region, as follows:

• Atlantic is $937
• Quebec is $1,204
• Ontario is $951
• Manitoba is $1,064
• Saskatchewan is $1,142
• Alberta is $1,010
• North is $801
• National is $1,028

Table 4.2: NIHB pharmacy utilization rates by region

Utilization rates represent the number of clients who received at least one pharmacy benefit paid through the HICPS system in the fiscal year, as a proportion of the total number of eligible clients.

In 2020 to 2021, the national utilization rate was 57% for NIHB Pharmacy benefits paid through the HICPS system. Utilization rates were impacted by provincial/territorial public health restrictions on travel and on the provision of in-person services due to the coronavirus (COVID-19) outbreak.

The rates understate the actual level of utilization as the data do not include pharmacy services provided through contribution agreements and benefits provided through community health facilities. For example, the HICPS system does not capture any data on services used by the Bigstone Cree Nation client population in Alberta and the Akwesasne client population in Ontario. If these populations were removed, the utilization rate for pharmacy benefits in Alberta would have been 64.4% and for Ontario the utilization rate for pharmacy benefits would have been 51.1% in 2020 to 2021. If both the Bigstone and Akwesasne client populations were removed from the overall NIHB population, the national utilization rate for pharmacy benefits would have been 58.0%.

Table 4.3: NIHB pharmacy claimants by age group, gender and region: 2020 to 2021

Of the 898,839 clients eligible to receive benefits under the NIHB program, a total of 508,596 claimants received at least one pharmacy item paid through the Health Information and Claims Processing Services (HICPS) system in 2020 to 2021. Of this total, 292,017 were female (57%) and 216,579 were male (43%). This compares to the total eligible population where 51% were female and 49% were male.

The average age of pharmacy claimants was 38 years. The average age for female and male claimants was 38 and 37 years of age, respectively.

Chart 4.5: Distribution of eligible NIHB population, pharmacy expenditures and pharmacy incidence by age group: 2020 to 2021

In 2020 to 2021, 4.1% of all clients were in the 0 to 4 age group, but this group accounted for only 0.4% of all pharmacy claims made and only 0.7% of total pharmacy expenditures. In contrast, 9.4% of all eligible clients were in the 65+ age group, but accounted for 24.3 % of all pharmacy claims submitted and 17.8% of total pharmacy expenditures.

During 2020 to 2021, the average claimant aged 65 or more submitted 93 claims compared to 72 claims for their counterpart in the 60 to 64 age group and 5 claims for the average claimant in the 0 to 4 age group.

Source: HICPS, FST and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 4.5: Distribution of eligible NIHB population, pharmacy expenditures and pharmacy incidence by age group: 2020 to 2021

This image is a bar graph which visually describes percentage of NIHB annual pharmacy expenditures and incidence by age group, as follows:

Age	Eligible clients	Incidence	Expenditures
0–4	4.1%	0.4%	0.7%
5–9	8.0%	0.7%	1.2%
10–14	9.2%	1.0%	2.1%
15–19	8.5%	1.7%	2.6%
20–24	8.6%	2.9%	4.0%
25–29	9.0%	5.7%	6.4%
30–34	8.2%	7.6%	7.8%
35–39	6.9%	7.9%	8.1%
40–44	6.1%	7.8%	8.1%
45–49	5.9%	8.7%	9.2%
50–54	5.9%	10.1%	10.6%
55–59	5.6%	10.9%	11.2%
60–64	4.6%	10.2%	10.3%
65+	9.4%	24.3%	17.8%
Total	100.0%	100.0%	100.0%

An examination of pharmacy benefit cost per NIHB claimant indicates that these expenditures vary according to age. For example, in 2020 to 2021 the average cost per child aged 0 to 4 years was $235. The cost increased steadily for every age group, with claimants aged 35-39 having an average cost of $1,112, comparable to the total average claimant cost of $1,028. Claimants aged 60-64 years had the highest cost per claimant with an average of $1,834 for all pharmacy claims received throughout the fiscal year.

Table 4.4: NIHB top ten therapeutic classes by number of claimants: 2020 to 2021

Table 4.4 ranks the top ten therapeutic classes according to number of claimants. In 2020 to 2021, Non-Steroidal Anti-Inflammatory Drugs (NSAID) had the highest number of distinct claimants at 168,759. Miscellaneous Analgesics and Antipyretics ranked second in number of claimants with 114,702 followed by Penicillins with 114,112 claimants.

Table 4.5: NIHB OTC (including CAD) drug claims incidence by therapeutic class: 2020 to 2021

Table 4.5 looks at the number of claims by therapeutic classification for over-the-counter (OTC) drugs.

Vitamins accounted for the largest number of OTC drug claims in 2020 to 2021 at 1.3 million paid claims, or 31.9% of all OTC claims. Central nervous systems agents had the next highest share of OTC claims at 945,284 (22.7%) followed by gastrointestinal drugs at 319,271 claims (7.7%).

Chart 5.1: Distribution of NIHB MS&E expenditures ($ millions): 2020 to 2021

The NIHB MS&E benefit is comprised of multiple components. The cost of medical equipment paid through the Health Information and Claims Processing Services (HICPS) system was the largest component, accounting for $32.7 million or 63.4% of all NIHB MS&E expenditures, followed by medical supplies paid through HICPS which totalled $17.0 million or 33.0%.

Contribution agreements, which accounted for $0.7 million or 1.4% of total MS&E benefit costs, are used to fund the provision of benefits through agreements such as those with the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Regional MS&E, which refers to MS&E items paid through Indigenous Services Canada regional offices, accounted for $0.6 million or 1.1%.

Other costs totalled $0.6 million or 1.1% of MS&E expenditures in 2020 to 2021. Included in this total are headquarters contract and claims processing expenditures related to the HICPS system.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 5.1: Distribution of NIHB MS&E expenditures ($ millions): 2020 to 2021

This image is a pie chart which visually describes NIHB medical supllies and equipment expenditures in millions and proportion of total expenditures by component type:

• medical supplies (HICPS) are $17.0 and 33.0%
• medical equipment (HICPS) are $32.7 and 63.4%
• other costs are $0.6 and 1.1%
• contribution agreements are $0.7 and 1.4%
• MS&E (regional) are $0.6 and 1.1%
• total expenditures $51.5

Table 5.1: Total NIHB MS&E expenditures by type and region ($ 000's): 2020 to 2021

Medical equipment costs paid through the HICPS system represented the largest component of total NIHB MS&E costs accounting for $32.7 million or 63.4%. The Saskatchewan region had the largest proportion of these costs at 23.3%, followed by Manitoba at 22.2% and Alberta at 19.3%.

The next highest component was medical supplies costs at $17.0 million or 33.0%. The regions of Saskatchewan (25.2%), Manitoba (20.4%) and Alberta (19.5%) had the largest proportions of these costs in 2020 to 2021.

All other MS&E expenditures, including contribution agreement costs, account for only 3.6% of total MS&E expenditure.

Chart 5.2: Annual NIHB MS&E expenditures

NIHB MS&E expenditures decreased by 3.2% during fiscal year 2020 to 2021, due in large part to the impact of the coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on the provision of in-person services. Over the past five years, growth in MS&E expenditures has ranged from a high of 9.4% in 2019 to 2020 to a low of -3.2% in 2020 to 2021.

The five year annualized growth rate for NIHB MS&E expenditures is 6.8%.

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 5.2: Annual NIHB MS&E expenditures

This is a bar graph which visually describes NIHB annual pharmacy expenditures in millions and percentage change by fiscal year, as follows:

• 2016 to 2017 are $37.0 and 8.3%
• 2017 to 2018 are $40.2 and 5.8%
• 2018 to 2019 are $46.5 and 2.5%
• 2019 to 2020 are $53.2 and 9.4%
• 2020 to 2021 are $51.5 and -3.2%

Chart 5.3: Per capita NIHB MS&E expenditures by region: 2020 to 2021

In 2020 to 2021, the national per capita expenditures for NIHB MS&E benefits was $56. This was a decrease of 6.2% from the $60 recorded in 2019 to 2020.

Alberta and Saskatchewan had the highest per capita NIHB MS&E expenditures at $75, followed by Manitoba at $69.

Quebec had the lowest per capita MS&E expenditures at $31 followed by Ontario at $33. Relatively low per capita expenditures in Quebec and Ontario are attributed to provincial programs which provide financial assistance for the provision of certain medical equipment items to all residents.

Source: FST and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 5.3: Per capita NIHB MS&E expenditures by region: 2020 to 2021

This image is a bar graph which visually describes NIHB MS&E expenditures per capita by region, as follows:

• Atlantic has $63
• Quebec has $31
• Ontario has $33
• Manitoba has $69
• Saskatchewan has $75
• Alberta has $75
• North has $56 and
• National has $56

Chart 5.4: NIHB MS&E expenditures per claimant by region: 2020 to 2021

Expenditures per claimant are based on the total cost of MS&E claims divided by the number of clients who submitted at least one MS&E claim.

In 2020 to 2021, the national average per claimant expenditure was $684. This is lower than the cost per claimant in either the pharmacy or dental benefit areas.

Alberta had the highest average NIHB MS&E expenditure per claimant at $991, followed by Saskatchewan at $732.

Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 5.4: NIHB MS&E expenditures per claimant by region: 2020 to 2021

This image is a bar graph which visually describes NIHB annual MS&E expenditures per claimant by region, as follows:

• Atlantic has $648
• Quebec has $455
• Ontario has $607
• Manitoba has $599
• Saskatchewan has $732
• Alberta has $991
• North has $695
• National has $684

Table 5.3: NIHB MS&E utilization rates by region

Utilization rates represent the number of clients who received at least one MS&E benefit paid through the HICPS system in the fiscal year, as a proportion of the total number of eligible clients.

In 2020 to 2021, the national utilization rate was 8% for NIHB MS&E benefits paid through the HICPS system.

The rates understate the actual level of utilization as the data do not include MS&E services provided through contribution agreements and benefits provided through community health facilities.

Table 5.4: NIHB MS&E claimants by age group, gender and region: 2020 to 2021

Of the 898,839 clients eligible to receive benefits under the NIHB program, a total of 74,467 claimants, representing 8.3% of the NIHB client population, received at least one MS&E item paid through the Health Information and Claims Processing Services (HICPS) system in 2020 to 2021. Of this total, 43,408 were female (58%) and 31,059 were male (42%). This compares to the total eligible population where 51% were female and 49% were male.

The average age of MS&E claimants was 50 years. The average age for female and male claimants was 50 and 49 years of age, respectively.

Chart 5.5: Distribution of eligible NIHB population, MS&E expenditures and MS&E incidence by age group: 2020 to 2021

In 2020 to 2021, 4.1% of all clients were in the 0 to 4 age group, but this group accounted for only 2.0% of all MS&E claims made and only 2.1% of total MS&E expenditures. In contrast, 9.4% of all eligible clients were in the 65+ age group, but accounted for 35.2 % of all MS&E claims submitted and 34.2% of total MS&E expenditures.

The average MS&E claimant submitted 5 claims in 2020 to 2021, a rate that is relatively consistent over all age groups.

Source: HICPS, FST and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 5.5: Distribution of eligible NIHB population, MS&E expenditures and MS&E incidence by age group: 2020 to 2021

This image visually describes NIHB annual MS&E expenditures and incidence by age group, as follows:

Age	Eligible Clients	Incidence	Expenditures
0–4	4.1%	2.0%	2.1%
5–9	8.0%	3.1%	3.6%
10–14	9.2%	2.8%	3.4%
15–19	8.5%	2.5%	2.6%
20–24	8.6%	2.8%	2.5%
25–29	9.0%	3.4%	3.0%
30–34	8.2%	3.7%	3.4%
35–39	6.9%	3.9%	3.7%
40–44	6.1%	4.7%	4.5%
45–49	5.9%	6.2%	6.3%
50–54	5.9%	8.5%	8.8%
55–59	5.6%	10.2%	10.7%
60–64	4.6%	11.0%	11.2%
65+	9.4%	35.2%	34.2%
Total	100.0%	100.0%	100.0%

Chart 5.6: NIHB medical supplies expenditures by category: 2020 to 2021

In 2020 to 2021, medical surgical supplies such as incontinence items accounted for 78.5% of all medical supply expenditures, an increase from the 75.1% recorded in 2019 to 2020. Audiology supplies, such as hearing aid batteries, represented 5.5% of all medical supply expenditures, followed by self-care supplies such as enteral feeding bags at 5.1%.

Source: HICPS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 5.6: NIHB medical supplies expenditures by category: 2020 to 2021

This bar graph visually describes percentage of NIHB medical equipment expenditures by category, as follows:

• medical surgical supplies is 78.5%
• audiology supplies is 5.5%
• self-care supplies is 5.1%
• prosthetic supplies is 4.3%
• oxygen supplies is 3.6%
• respiratory supplies is 1.8%
• all others is 1.2%

Chart 5.7: NIHB medical equipment expenditures by category: 2020 to 2021

In 2020 to 2021, mobility equipment such as wheelchairs accounted for 20.9% of all medical equipment expenditures, an increase from the 19.6% recorded in 2019 to 2020. Audiology equipment, such as hearing aids, represented 18.1% of all medical equipment expenditures, followed by self-care equipment such as blood pressure monitors at 5.1%.

Source: HICPS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 5.7: NIHB medical equipment expenditures by category: 2020 to 2021

This bar graph visually describes percentage of NIHB medical equipment expenditures by category, as follows:

• mobility equipment is 20.9%
• audiology equipment is 18.1%
• self-care equipment is 13.7%
• respiratory equipment is 13.4%
• oxygen equipment is 9.7%
• orthotics equipment is 7.1%
• all others is 17.1%

Chart 6.1: Distribution of NIHB dental expenditures ($ millions): 2020 to 2021

NIHB dental expenditures are comprised of multiple distinct components. Fee-for-service dental costs paid through HICPS system represented the largest expenditure portion, accounting for $210.9 million or 89.3% of all NIHB dental costs.

The next highest component was contribution agreements, which accounted for $14.6 million or 6.2% of total dental expenditures. Contribution agreements are used to fund the provision of dental benefits through agreements such as those with the Mohawk Council of Akwesasne in Ontario and the Bigstone Cree Nation in Alberta.

Expenditures for contract dentists providing services to clients in remote communities totalled $7.7 million or 3.3% of total costs.

Other costs totalled $3.1 million or 1.3% in 2020 to 2021. The majority of these costs are related to benefit claims processing through the HICPS system.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 6.1: Distribution of NIHB dental expenditures ($ millions): 2020 to 2021

This image is a pie chart which visually describes NIHB dental expenditures in millions by component type.

• expenditures for fee-for-service (HICPS) are $210.9 and 89.3%
• contract dentists is $7.7 and 3.3%
• other costs is $5.4 and 1.9%
• contribution agreements is $14.6 and 6.2%
• total dental expenditures are $236.3

Table 6.1: Total NIHB dental expenditures by type and region ($ 000's): 2020 to 2021

Of the $236.3 million in NIHB dental expenditures in 2020 to 2021, Alberta (20.2%), Saskatchewan (20.1%), Ontario (20.0%) and Manitoba (18.7%) had the largest overall proportion. Alberta had the highest total dental expenditures at $47.7 million and the Atlantic region had the lowest total dental expenditures at $9.5 million.

Chart 6.2: NIHB Dental expenditures and annual percentage change

NIHB dental expenditures decreased by 16.5% during fiscal year 2020 to 2021, due in large part to the impact of the coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on the provision of in-person care.

Over the last five years, annual growth rates for NIHB dental expenditures have ranged from a high of 8.6% in 2016 to 2017 to a low of negative 16.5% in 2020 to 2021.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 6.2: NIHB Dental expenditures and annual percentage change

This image is a bar graph which visually describes NIHB dental expenditures in millions and annual percentage change by fiscal year, as follows:

• 2016 to 2017 is $235.8 and 8.6%
• 2017 to 2018 is $249.0 and 5.6%
• 2018 to 2019 is $269.0 and 8.0%
• 2019 to 2020 is $282.9 and 5.2%
• 2020 to 2021 is $236.3 and -16.5%

Chart 6.3: Per capita NIHB dental expenditures by region: 2020 to 2021

In 2020 to 2021, national per capita NIHB dental expenditures were $259, a decrease of 17.0% from $313 in 2019 to 2020.

Alberta had the highest per capita dental expenditures at $372, followed by Saskatchewan at $299 and the Northern region at $282. The Atlantic region had the lowest per capita dental expenditures at $142 per eligible client.

Per capita values reflect NIHB dental expenditures only, and do not include additional dental services that may be provided to First Nations and Inuit populations through other Indigenous Services Canada programs or through transfers and other arrangements.

Source: FST and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 6.3: Per capita NIHB dental expenditures by region: 2020 to 2021

This image is a bar graph which visually describes NIHB dental expenditures per capita by region, as follows:

• Atlantic has $142
• Quebec has $196
• Ontario has $216
• Manitoba has $274
• Saskatchewan has $299
• Alberta has $372
• North has $282
• National has $259

Chart 6.4: NIHB dental fee-for-service expenditures per claimant by region: 2020 to 2021

In 2020 to 2021, national NIHB dental expenditures per claimant, meaning eligible clients who received at least one dental service paid through HICPS, was $790, an increase of 1.8% over the $776 reported in 2019 to 2020.

Alberta had the highest dental expenditures per claimant at $988 followed by the Northern region at $940. Manitoba saw the largest increase in dental cost per claimant, to $866, up from $753 in 2019 to 2020.

Source: FST and HICPS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 6.4: NIHB dental fee-for-service expenditures per claimant by region: 2020 to 2021

This image is a bar graph which visually describes NIHB dental expenditures per claimant by region, as follows:

• Atlantic has $465
• Quebec has $572
• Ontario has $674
• Manitoba has $866
• Saskatchewan has $865
• Alberta has $988
• North has $940
• National has $790

Table 6.3: NIHB dental utilization rates by region

Utilization rates reflect the number of clients who, during the fiscal year, received at least one dental service paid through the HICPS system as a proportion of the total number of eligible clients.

In 2020 to 2021, the national utilization rate for dental benefits paid through the HICPS system was 30%. National NIHB dental utilization rates were impacted by provincial/territorial public health restrictions on the provision of in-person services due to the coronavirus (COVID-19) outbreak.

Dental utilization rates vary across the regions with the highest dental utilization rate found in Alberta and Quebec at 36% and 34% respectively. The lowest dental utilization rate was in Ontario (26%). Please note that the dental utilization rates understate the actual level of access, as these data do not include contract dental services provided in some regions or dental services provided through contribution agreements. For example, HICPS data does not capture any services utilized by the Bigstone Cree Nation. If this client population was removed from the Alberta Region's population, the utilization rate for dental benefits for Alberta would have been 38% in 2020 to 2021. The same scenario would apply for the Ontario Region. If the Akwesasne client population in Ontario were to be removed, the utilization rate for dental benefits in Ontario would have been 28%. The utilization rate also does not reflect services received through Indigenous Services Canada programs such as Community Oral Health Services and the Children's Oral Health Initiative (COHI).

Over the two year period between 2019 to 2020 and 2020 to 2021, 412,876 distinct clients received NIHB dental services through HICPS, resulting in an overall 46% utilization rate over this period.

Table 6.4: NIHB dental claimants by age group, gender and region: 2020 to 2021

Of the 898,839 clients eligible to receive dental benefits through the NIHB program, 267,032 claimants (30%) received at least one dental procedure paid through the HICPS system in 2020 to 2021.

Of this total, 152,023 were female (57%) and 115,009 were male (43%), compared to the total eligible NIHB population where 51% were female and 49% were male.

The average age of dental claimants was 33 years, indicating clients tend to access dental services at a slightly younger age compared to pharmacy services (38 years of age). The average age for female and male claimants was 34 and 32 years of age respectively.

Approximately 33% of all dental claimants were under 20 years of age. 36% of male claimants were in this age group compared to 30% of female claimants. Approximately 7% of all claimants were seniors aged 65 and over in 2020 to 2021.

NIHB fee-for-service dental expenditures by service category: 2020 to 2021

In 2020 to 2021, expenditures for restorative services (crowns, fillings, etc.) were the highest of all dental service categories at $92.0 million. Diagnostic services (examinations, x-rays, etc.) at $26.9 million and preventive services (scaling, sealants, etc.) at $23.6 million were the next highest service categories. Rounding out the top 5 were oral surgery (extractions, etc.) at $22.0 million and endodontic services (root canal treatments, etc.) at $17.2 million.

In 2020 to 2021, the three highest dental procedures by expenditure were composite restorations ($79.4 million), scaling ($17.9 million) and extractions ($15.9 million).

Chart 6.5: Distribution of eligible NIHB population, dental expenditures and incidence by age group: 2020 to 2021

The ratio of incidence to expenditures is relatively consistent across most age groupings; however, there are notable exceptions. For children aged 5 to 14, a larger number of low-cost procedures, such as fillings, are provided, so this group accounts for 20.7% of claims, but only 15.3% of expenditures.

Source: HICPS and SVS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 6.5: Distribution of eligible NIHB population, dental expenditures and incidence by age group: 2020 to 2021

This image visually describes distribution percentage of NIHB dental clients, incidence and expenditures by age group, as follows:

Age	Eligible Clients	Expenditures	Incidence
0–4	4.1%	3.9%	3.7%
5–9	8.0%	9.3%	6.3%
10–14	9.2%	11.3%	9.0%
15–19	8.5%	10.3%	11.1%
20–24	8.6%	8.9%	9.8%
25–29	9.0%	9.2%	9.9%
30–34	8.2%	8.2%	8.7%
35–39	6.9%	6.8%	7.1%
40–44	6.1%	5.9%	6.1%
45–49	5.9%	5.7%	6.0%
50–54	5.9%	5.7%	6.1%
55–59	5.6%	5.2%	5.5%
60–64	4.6%	3.9%	4.2%
65+	9.4%	5.7%	6.5%
Total	100.0%	100.0%	100.0%

Chart 7.1: Distribution of NIHB medical transportation expenditures ($ millions): 2020 to 2021

In 2020 to 2021, NIHB medical transportation expenditures totalled $525.7.million. Transportation expenditures in 2020 to 2021 were impacted by the coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on travel and on the provision of in-person services.

Contribution agreements for the management of medical transportation benefits by First Nations bands, territorial governments and other organizations represented the largest component, accounting for $278.7 million, or 53.0% of total benefit expenditures.

Of benefits managed by the NIHB program, living expenses at $65.75 million (12.5%), scheduled flights at $43.2 million (8.2%) and land ambulance at $49.6 million (9.4%) were the largest expenditures, accounting for a combined total of over 30%.

Rounding out medical transportation expenditures are costs for air ambulance at $47.8 million (9.1%), chartered flights at $21.8 million (4.1%), and land and water transportation at $19.0 million (3.6%).

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 7.1: Distribution of NIHB medical transportation expenditures ($ millions): 2020 to 2021

This image is a pie chart which visually describes NIHB medical transportation expenditures and percentage by type, as follows:

• scheduled flights is 43.2, 8.2%
• living expenses is $65.7, 12.5%
• land ambulance is $49.6, 9.4%
• air ambulance is $47.8, 9.1%
• land and water is $19.1, 3.6%
• chartered flights is $21.8, 4.1%
• contribution agreements is $278.7, 53.0%
• total is $525.7

Chart 7.2: Annual NIHB medical transportation expenditures

NIHB medical transportation expenditures decreased by 2.1% in 2020 to 2021 compared to the previous year. Over the past five years, overall medical transportation costs have grown by 26.1% from $417.0 million in 2016 to 2017 to $525.7 million in 2020 to 2021.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 7.2: Annual NIHB medical transportation expenditures

This image is a bar graph which visually describes NIHB medical transportation expenditures and percentage growth by year, as follows:

• 2016 to 2017 expenditures are $417.0 and percentage change 10.9%
• 2017 to 2018 are $459.5 and 10.2%
• 2018 to 2019 are $495.0 and 7.7%
• 2019 to 2020 are $537.2 and 8.5%
• 2020 to 2021 are $525.7 and -2.1%

On a regional basis, the highest 5 year growth rates were in the Northern region where expenditures grew by 74.5% from $55.1 million in 2016 to 2017 to $96.2 million in 2020 to 2021. This was followed by Saskatchewan with an increase of 44.2% from $58.9 million in 2016 to 2017 to $85.0 million in 2020 to 2021.

Manitoba had the highest total medical transportation expenditures at $155.8 million in 2020 to 2021, followed by the Northern region at $96.2 million and Ontario at $90.6 million.

Table 7.2: NIHB medical transportation expenditures by type and region ($ 000's): 2020 to 2021

All regions, except for the Northern Region and Saskatchewan, experienced a decrease in medical transportation expenditures in fiscal year 2020 to 2021 due to the effects of the coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on travel and the provision of in-person services. The Northern Region, which saw an increase in medical transportation expenditures in this period of 25.6% from the previous fiscal year, was also impacted by provincial/territorial quarantine and social distancing requirements for clients travelling out of community, resulting in an increase to the number of trips needed to facilitate necessary travel. Saskatchewan followed the Northern Region with an 1.2% increase in medical transportation expenditures.

In 2020 to 2021 Manitoba had the highest overall NIHB medical transportation expenditures at $155.8 million, primarily as a result of air transportation, which totalled $79.2 million. High medical transportation costs in the region reflect in part the large number of First Nations clients living in remote or fly-in only northern communities.

The Northern region represented the second highest medical transportation expenditures total in 2020 to 2021 at $96.2 million. Ontario and Saskatchewan followed at $90.6 million and $85.0 million, respectively.

Chart 7.3: NIHB medical transportation contribution and operating expenditures by region ($ millions): 2020 to 2021

Contribution funding is provided to First Nations bands, territorial governments and other organizations to manage elements of the medical transportation benefit such as coordinating accommodations or managing ground transportation, whereas operating costs are medical transportation benefits that are managed directly by Indigenous Services Canada regional offices.

Manitoba region had the largest operating expenditures for NIHB medical transportation in 2020 to 2021 at $113.1 million. This higher cost in the Manitoba region is due largely to the high number of clients living in remote or fly-in only communities in the northern areas of the province who require air travel to access health services in Winnipeg. Saskatchewan had the next largest operating expenditures at $58.9 million, followed by Ontario at $43.4 million. Together these three regions accounted for 87.2% of all operating expenditures for medical transportation.

In 2020 to 2021, the Northern region had the largest contribution expenditures for NIHB medical transportation at $90.9 million, followed by the regions of Ontario and Manitoba at $47.3 million and $42.7 million, respectively. Almost all NIHB medical transportation services were delivered via contribution agreements in Quebec.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 7.3: NIHB medical transportation contribution and operating expenditures by region ($ millions): 2020 to 2021

This image visually describes NIHB medical transportation expenditures by region and type, as follows:

Total contribution expenditures for:

• Atlantic are $9.4
• Quebec are $24.8
• Ontario are $47.3
• Manitoba are $42.7
• Saskatchewan are $26.1
• Alberta are $37.5
• North are $90.9

Total operating expenditures for:

• Atlantic are $3.8
• Quebec are $0.6
• Ontario are $43.4
• Manitoba are $113.1
• Saskatchewan are $58.4
• Alberta are $22.0
• North are $5.3

Chart 7.4: NIHB medical transportation operating expenditures by type ($ millions): 2020 to 2021

In 2020 to 2021, living expenses, which include accommodations and meals, represented the largest portion of NIHB's medical transportation operating expenditures at $65.7 million or 26.6% of the total national operating expenditures. Land ambulance was the second highest at $49.6 million, or 20.1% of operating expenditures. Air ambulance followed at $47.8 million or 19.3%, and scheduled flights comprised $43.2 million or 17.5% of medical transportation operating costs.

Private vehicle expenditures ($3.5 million) are the costs reimbursed through a per-kilometre allowance for private vehicle used by a client to access eligible health services. The NIHB private vehicle kilometric allowance rates are directly linked to the National Joint Council's (NJC) Government Commuting Assistance Directive Lower Kilometric Rates.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 7.4: NIHB medical transportation operating expenditures by type ($ millions): 2020 to 2021

This bar graph visually describes NIHB medical transportation expenditures by category, in millions, as follows:

• living expenses is $65.7
• land ambulance is $49.6
• air ambulance is $50.9
• scheduled air is $43.2
• chartered flights is $21.8
• land taxi is $12.4
• private vehicle is $3.5
• other land and water is $3.1

Chart 7.5: Per capita NIHB medical transportation expenditures by region: 2020 to 2021

In 2020 to 2021, the national per capita expenditures for NIHB medical transportation benefits was $602.

The Northern region recorded the highest per capita expenditures in medical transportation at $1,332, followed by Manitoba at $968. These expenditures reflect the large number of First Nations and Inuit clients living in remote or fly-in communities that need to fly south for health services.

In contrast, the Atlantic region had the lowest per capita expenditures at $199, a slight decrease from $213 in the previous year. Compared to other regions, this lower per capita cost is reflective of the geography of the region, which allows easier access to health services with less need for air travel.

Source: SVS and FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 7.5: Per capita NIHB medical transportation expenditures by region: 2020 to 2021

This bar graph visually describes NIHB per capita medical transportation expenditures by region, as follows:

• Atlantic at $199
• Quebec at $334
• Ontario at $414
• Manitoba at $968
• Saskatchewan at $535
• Alberta at $464
• North at $1,332
• National at $602

Table 8.1: NIHB vision care expenditures and growth by region ($ 000's): 2020 to 2021

NIHB vision care expenditures totalled $39.6 million in 2020 to 2021. Regional operating expenditures accounted for $35.5 million (89.7%) of total expenditures while contribution costs accounted for $4.1 million (10.3%).

In 2020 to 2021 Saskatchewan had the highest expenditures in NIHB vision benefits at $8.5 million, a percentage share of 21.5%, followed by Alberta at $6.4 million (20.3%) and Ontario at $6.8 million (18.6%).

Chart 8.1: Annual NIHB vision care expenditures

In 2020 to 2021, NIHB vision care expenditures decreased by 13.9% from the previous year. The coronavirus (COVID-19) outbreak and provincial/territorial public health restrictions on the provision of in-person services contributed to this decrease.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 8.1: Annual NIHB vision care expenditures

This image is a bar graph which visually describes NIHB vision care expenditures by year in millions and percentage change, as follows:

• 2016 to 2017 is $32.4 and 7.8%
• 2017 to 2018 is $33.6 and 3.7%
• 2018 to 2019 is $36.5 and 8.6%
• 2019 to 2020 is $46.0 and 26.1%
• 2020 to 2021 is $39.6 and -13.9%

On a regional basis, the highest growth rate over this five year period was in Quebec where expenditures grew by 59.7% from $1.8 million in 2016 to 2017 to $2.8 million in 2020 to 2021. Saskatchewan had largest net increase in expenditures over this period, where costs grew by $2.4 million.

Chart 8.2: Per capita NIHB vision care expenditures by region: 2020 to 2021

In 2020 to 2021, national per capita expenditures in NIHB vision care benefits were $44.

Alberta had the highest per capita expenditures at $63, followed by Saskatchewan at $53 and the Atlantic region at $51. The lowest per capita NIHB vision care benefit expenditures were in Ontario at $34.

Source: SVS and FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 8.2: Per capita NIHB vision care expenditures by region: 2020 to 2021

This image visually describes NIHB per capita vision care expenditures by region, as follows:

• Atlantic $51
• Quebec $37
• Ontario $34
• Manitoba $38
• Saskatchewan $53
• Alberta $63
• North $44
• National $44

Table 8.3: NIHB mental health counselling expenditures by region ($ 000's): 2020 to 2021

In 2020 to 2021, NIHB mental health counselling expenditures amounted to $73.7 million. Regional operating expenditures accounted for $46.7 million (63.3%) of total expenditures, while contribution costs accounted for $27.0 million (36.7%).

In 2020 to 2021, Saskatchewan had the highest percentage share of NIHB mental health counselling expenditures at 22.8%, followed by Ontario and Manitoba at 21.0% and 18.7% respectively.

Chart 8.3: NIHB mental health counselling expenditures and annual percentage change

NIHB mental health counselling expenditures increased by 33.6% during fiscal year 2020 to 2021. Over the past five years, overall mental health counselling costs have grown by 239.0% from $21.7 million in 2016 to 2017 to $73.7 million in 2020 to 2021. Budget 2017 provided funding to expand the benefit by removing the requirement that counselling be provided in response to a crisis.

Source: FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 8.3: NIHB mental health counselling expenditures and annual percentage change

This image visually describes NIHB mental health counselling expenditures and annual percentage change by year, as follows:

• 2016 to 2017 is $21.7 and 34.2%
• 2017 to 2018 is $33.1 and 52.2%
• 2018 to 2019 is $42.7 and 29.0%
• 2019 to 2020 is $55.1 and 29.2%
• 2020 to 2021 is $73.3 and 33.6%

On a regional basis, the highest growth rates over this period were in the North where expenditures grew by 977.6% from $362 thousand in 2016 to 2017 to $3.9 million in 2020 to 2021. This was followed by the Atlantic region with an increase of 904.8% from $601 thousand in 2016 to 2017 to $6.0 million in 2020 to 2021.

Chart 8.4: Per capita NIHB mental health counselling expenditures by region ($ 000's): 2020 to 2021

In 2020 to 2021, the national per capita expenditures for NIHB Mental Health Counselling were $82 per NIHB-eligible client.

Saskatchewan had the highest per capita expenditures at $106, followed by Alberta at $100 per NIHB-eligible client.

Source: SVS and FST adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 8.4: Per capita NIHB mental health counselling expenditures by region ($ 000's): 2020 to 2021

This image visually describes NIHB mental health counselling per capita expenditures, as follows:

• Atlantic is $90
• Quebec is $59
• Ontario is $71
• Manitoba is $86
• Saskatchewan is $106
• Alberta is $100
• North is $44
• National $82

Table 8.5: NIHB other health care expenditures by region: 2020 to 2021

In 2020 to 2021, NIHB other expenditures totalled $12.3 million. The majority of these expenditures are related to contribution agreements, including funding arrangements with the FNHA for clients eligible under Bill C-3 and S-3, and Qalipu clients.

Other expenditures in this category include contribution agreements with national client partner organizations, such as the Assembly of First Nations and Inuit Tapiriit Kanatami, as well as with regional First Nations and Inuit organizations that employ NIHB Navigators to act as a resource for communities, organizations or individuals who need assistance or information on the NIHB program.

Atlantic region

Annual expenditures in the Atlantic Region for 2020 to 2021 totalled $74.0 million, an increase of 1.2% over the $73.1 million spent in 2019 to 2020. Pharmacy expenditures in 2020 to 2021 increased by 5.5% to $37.3 million, medical transportation costs decreased by 4.7% to $13.3 million and dental expenditures decreased by 18.1% to $9.4 million. Mental health expenditures increased by 76.1%, MS&E expenditures decreased by 4.2% and vision care expenditures decreased by 17.2%.

Pharmacy expenditures accounted for half of the Atlantic Region's total expenditures at 50.4%. Medical transportation expenditures ranked second at 17.9%, followed by dental at 12.8%. MS&E, vision care and mental health expenditures accounted for 5.6%, 8.2% and 4.6% of total expenditures respectively. Certain NIHB benefit areas had a decrease in expenditures over the previous fiscal year due in large part to provincial/territorial public health restrictions on travel and the provision of in-person services due to the effects of the coronavirus (COVID-19) outbreak.

Over the ten year period from fiscal year 2011 to 2012 to fiscal year 2020 to 2021, NIHB expenditures in the Atlantic Region were impacted by changes to the NIHB eligible client population. The creation of the Qalipu Mi'kmaq First Nation band in 2011 resulted in a 2 year surge in Atlantic Regional expenditures. As of March 31, 2020, a total of 23,855 Qalipu clients were eligible to receive benefits through the NIHB program. The decrease in expenditures in 2013 to 2014 can be attributed to the transfer of authority to the First Nations Health Authority for clients registered to Atlantic First Nations, but residing in British Columbia.

Chart 9.1: Percentage change in Atlantic region NIHB expenditures ($ 000's)

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 9.1: Percentage change in Atlantic region NIHB expenditures ($ 000's)

This image visually describes NIHB expenditures and annual percentage change in the Atlantic region, as follows:

Atlantic region	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Total expenditures ($M)	$42,850	$49,995	$46,033	$46,912	$50,773	$55,079	$60,040	$63,342	$73,071	$73,984
Total benefits annual % change	14.3%	16.7%	-7.9%	1.9%	8.2%	8.5%	9.0%	5.5%	15.4%	1.2%

Quebec

Annual expenditures in Quebec for 2020 to 2021 totalled $103.8 million, a decrease of 0.3% from the $104.1 million spent in 2019 to 2020.

Pharmacy expenditures increased by 5.0% to $53.3 million and dental expenditures decreased by 20.3% to $14.9 million in 2020 to 2021, while medical transportation costs decreased by 1.4% to $25.4 million. MS&E expenditures decreased by 7.2%, mental health expenditures increased by 43.2% and vision care expenditures increased by 2.8%. Certain NIHB benefit areas had a decrease in expenditures over the previous fiscal year due in large part to provincial/territorial public health restrictions on travel and the provision of in-person services due to the effects of the coronavirus (COVID-19) outbreak.

Pharmacy expenditures accounted for more than half of the Quebec region's total expenditures in 2020 to 2021 at 51.3%. Medical transportation expenditures ranked second at 24.5%, followed by dental at 14.4%. Mental health counselling, vision care expenditures, and MS&E accounted for 4.3%, 2.7% and 2.3% of total expenditures respectively.

Chart 9.2: Percentage change in Quebec NIHB expenditures ($ 000's)

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 9.2: Percentage change in Quebec NIHB expenditures ($ 000's)

This image visually describes NIHB expenditures and annual percentage change in the Quebec region, as follows:

Quebec region	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Total expenditures ($M)	$77,951	$80,915	$80,608	$84,666	$87,690	$91,831	$94,210	$96,120	$104,136	$103,773
Total benefits annual % change	4.8%	3.8%	-0.4%	5.0%	3.6%	4.7%	2.6%	2.0%	8.3%	-0.3%

Ontario

Annual expenditures in Ontario for 2020 to 2021 totalled $274.0 million, a decrease of 4.7% from the $287.6 million spent in 2019 to 2020.

In 2020 to 2021, Ontario pharmacy expenditures increased by 8.1% to $105.3 million, while medical transportation costs decreased by 15.0% to $90.6 million. Mental health counselling expenditures increased by 27.9%, while vision care expenditures decreased by 6.5% and MS&E decreased by 0.3%. Certain NIHB benefit areas had a decrease in expenditures over the previous fiscal year due in large part to provincial/territorial public health restrictions on travel and the provision of in-person services due to the effects of the coronavirus (COVID-19) outbreak.

Pharmacy expenditures accounted for 38.4% of total expenditures for Ontario. Medical transportation costs ranked second at 33.1%, followed by dental at 17.2%. Mental health, MS&E and vision care expenditures accounted for 4.7%, 2.7% and 2.7% of total expenditures respectively.

Chart 9.3: Percentage change in Ontario NIHB expenditures ($ 000's)

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 9.3: Percentage change in Ontario NIHB expenditures ($ 000's)

This image visually describes NIHB expenditures and annual percentage change in the Ontario region, as follows:

Ontario	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Total expenditures ($M)	$180,778	$186,544	$193,929	$203,043	$215,738	$231,663	$250,947	$269,127	$287,643	$273,987
Total benefits annual % change	3.5%	3.2%	4.0%	4.7%	6.3%	7.4%	8.3%	7.2%	6.9%	-4.7%

Manitoba

Annual expenditures in Manitoba for 2020 to 2021 totalled $337.5 million, a decrease of 4.1% from the $352.0 million spent in 2019 to 2020. Pharmacy expenditures in 2020 to 2021 increased by 6.8% to $106.9 million, while medical transportation costs decreased by 7.6% to $155.8 million. MS&E expenditures decreased by 6.9% to $11.1 million, while dental expenditures decreased by 16.1% to $44.1 million. Mental health expenditures increased by 20.3% while vision care expenditures decreased by 20.3%. Certain NIHB benefit areas had a decrease in expenditures over the previous fiscal year due in large part to provincial/territorial public health restrictions on travel and the provision of in-person services due to the effects of the coronavirus (COVID-19) outbreak.

Unlike most other regions, pharmacy expenditures in Manitoba do not represent the largest proportion of total expenditures. Due to the higher proportion of clients living in northern or remote communities in Manitoba, medical transportation expenditures comprised almost half of Manitoba's total expenditures at 46.2%. Pharmacy costs ranked second at 31.7%, followed by dental at 13..%. Mental health, MS&E and vision care expenditures accounted for 4.1%, 3.3% and 1.6% of total expenditures respectively.

Chart 9.4: Percentage change in Manitoba NIHB expenditures ($ 000's)

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 9.4: Percentage change in Manitoba NIHB expenditures ($ 000's)

This image visually describes NIHB expenditures and annual percentage change in the Manitoba region, as follows:

Manitoba	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Total expenditures ($M)	$219,031	$228,295	$229,670	$239,190	$258,077	$291,989	$308,208	$320,953	$351,983	$337,517
Total benefits annual % change	5.6%	4.2%	0.6%	4.1%	7.9%	13.1%	5.6%	4.1%	9.7%	-4.1%

Saskatchewan

Annual expenditures in Saskatchewan for 2020 to 2021 totalled $286.0 million, a decrease of 1.5% from the $290.4 million spent in 2019 to 2020.

Saskatchewan is the region with the highest expenditures in pharmacy, followed closely by Manitoba and Ontario. In Saskatchewan, pharmacy expenditures increased by 1.0% to $116.2 million, while medical transportation costs increased by 1.2% to $85.0 million. MS&E expenditures increased by 0.2% to $11.9 million and dental expenditures decreased by 17.6% to $47.5 million. Mental health expenditures increased by 42.3% and vision care expenditures decreased by 13.7%. Certain NIHB benefit areas had a decrease in expenditures over the previous fiscal year due in large part to provincial/territorial public health restrictions on travel and the provision of in-person services due to the effects of the coronavirus (COVID-19) outbreak.

Pharmacy expenditures comprised the largest portion of Saskatchewan's total expenditures at 40.6%, medical transportation costs ranked second at 29.7%, followed by dental at 16.6%. Mental health, MS&E and vision care expenditures accounted for 5.9%, 4.2% and 3.0% of total expenditures respectively.

Chart 9.5: Percentage change in Saskatchewan NIHB expenditures ($ 000's)

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 9.5: Percentage change in Saskatchewan NIHB expenditures ($ 000's)

This image visually describes NIHB expenditures and annual percentage change in the Saskatchewan region, as follows:

Saskatchewan	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Total expenditures ($M)	$161,265	$163,372	$168,752	$180,000	$193,502	$220,352	$247,997	$265,082	$290,386	$286,028
Total benefits annual % change	5.1%	1.3%	3.3%	6.7%	7.5%	13.9%	12.5%	6.9%	9.5%	-1.5%

Alberta

Annual expenditures in Alberta for 2020 to 2021 totalled $223.0 million, a decrease of 4.0% from the $232.2 million spent in 2019 to 2020. Pharmacy expenditures increased by 1.7% to $84.9 million, while medical transportation costs decreased by 3.5% to $59.5 million. MSE expenditures decreased by 5.9% to $9.6 million and dental expenditures decreased by 13.2% to $47.7 million. Mental health expenditures increased by 16.5% to $12.8 million and vision care expenditures decreased by 23.6%. to $8.0 million. Certain NIHB benefit areas had a decrease in expenditures over the previous fiscal year due in large part to provincial/territorial public health restrictions on travel and the provision of in-person services due to the effects of the coronavirus (COVID-19) outbreak.

Pharmacy expenditures accounted for 38.1% of Alberta's total expenditures. Medical transportation costs ranked second at 26.7%, followed closely by dental at 21.4%. Mental health, MS&E and vision care expenditures accounted for 5.8%, 4.3% and 3.6% of total expenditures respectively.

Chart 9.6: Percentage change in Alberta NIHB expenditures ($ 000's)

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 9.6: Percentage change in Alberta NIHB expenditures ($ 000's)

This image visually describes NIHB expenditures and annual percentage change in the Alberta region, as follows:

Alberta	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Total expenditures ($M)	$143,313	$144,928	$146,051	$158,911	$168,211	$183,108	$192,983	$209,122	$232,177	$222,953
Total benefits annual % change	3.3%	1.1%	0.8%	8.8%	5.8%	8.9%	5.4%	8.4%	11.0%	-4.0%

Northern region

Annual expenditures in the Northern region for 2020 to 2021 totalled $157.7 million, an increase of 10.3 % from the $143.0 million spent in 2019 to 2020.

Medical transportation expenditures in 2020 to 2021 increased by 25.6% to $96.2 million while pharmacy costs increased by 4.0% to $29.5 million. MS&E expenditures decreased by 17.6% to $4.0 million and dental expenditures decreased by 23.4% to $20.3 million. Mental health expenditures increased by 79.8% to $3.9 million and vision care expenditures decreased by 18.4% to $3.2 million. Certain NIHB benefit areas had a decrease in expenditures over the previous fiscal year due in large part to provincial/territorial public health restrictions on travel and the provision of in-person services due to the effects of the coronavirus (COVID-19) outbreak. The Northern region also faced increased medical transportation costs related to quarantine requirements.

Similar to Manitoba, medical transportation expenditures comprised the largest portion of the Northern region's total expenditures at 61.0%. Pharmacy costs ranked second at 18.7%, followed by dental at 12.9%. MS&E, mental health, and vision care expenditures accounted for 2.6%, 2.5% and 2.0% of total expenditures respectively.

Chart 9.7: Percentage change in Northern Region NIHB expenditures ($ 000's)

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 9.7: Percentage change in Northern Region NIHB expenditures ($ 000's)

This image visually describes NIHB expenditures and annual percentage change in the Northern region, as follows:

Northern region	2011 to 2012	2012 to 2013	2013 to 2014	2014 to 2015	2015 to 2016	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Total expenditures ($M)	$87,787	$88,557	$92,027	$94,343	$102,040	$109,157	$126,933	$134,474	$142,961	$157,664
Total benefits annual % change	2.4%	0.9%	3.9%	2.5%	8.2%	7.0%	16.3%	5.9%	6.3%	10.3%

Non-insured health benefits administration costs ($ 000's): 2020 to 2021

This table outlines program administration expenditures by region as well as NIHB headquarters (HQ) in Ottawa. In 2020 to 2021, total NIHB administration costs were $73.4 million representing a decrease of 3.1% over the previous fiscal year.

The roles of NIHB headquarters include:

• program policy development and determination of eligible benefits
• development and maintenance of the HICPS system and other national systems such as the Medical Transportation Reporting System (MTRS)
• claims verification and provider negotiations
• adjudicating benefit requests through the NIHB Drug Exception Centre and the Dental Predetermination Centre
• providing expert advice through the MS&E Review Centre and
• maintaining relationships with partner organizations at the national level as well as with other federal departments and agencies.

The roles of the NIHB regional offices include:

• adjudicating benefit requests for medical transportation, medical supplies and equipment, vision care, and mental health counselling benefits
• maintaining relationships with partner organizations at the provincial/territorial level as well as with provincial/territorial officials
• managing contribution agreements (CA)

Claims processing contract costs are related to the administration of pharmacy, medical supplies and equipment, dental benefits, mental health counselling and vision care benefits through the Health Information and Claims Processing Services (HICPS) system, and include:

• claim processing and payment operations
• claim adjudication and reporting systems development and maintenance
• provider registration and communications
• provider verification programs and recoveries and
• standard and ad hoc reporting.

Chart 10.1: Non-Insured Health Benefits administration costs as a proportion of benefit expenditures ($ millions)

In 2020 to 2021, total NIHB benefit expenditures were $1,490.6 million, of which direct benefit expenditures totaled $1,435.7 million and expenditures for claims processing administration amounted to $18.5 million. An additional $54.9 million was spent on salaries and operating costs associated with program administration.

Total NIHB program administration costs ($73.4 million, including claims processing and other program administration) as a proportion of direct benefit expenditures ($1.4 billion), was 5.0% in 2020 to 2021. Over the past five fiscal years, the percentage of NIHB program administrative costs as a proportion of total benefit expenditures has ranged from a high of 5.1% in 2019 to 2020 to a low of 4.7% the previous three fiscal years.

Source: FST and FIRMS adapted by Business Support, Audit and Negotiations Division

Text alternative for Chart 10.1: Non-Insured Health Benefits administration costs as a proportion of benefit expenditures ($ millions)

Fiscal year	NIHB benefit expenditures ($M)	% Administrative costs
2016 to 2017	$1,207.5	4.7%
2017 to 2018	$1,309.2	4.7%
2018 to 2019	$1,390.2	4.7%
2019 to 2020	$1,519.5	5.1%
2020 to 2021	$1,490.6	5.0%

Health Information and Claims Processing Services (HICPS): 2020 to 2021

Claims for NIHB pharmacy, dental and MS&E benefits provided to eligible First Nations and Inuit clients are processed via the Health Information and Claims Processing Services (HICPS) system. NIHB mental health and vision care benefit claims are processed via HICPS as of June 28, 2020 and will be reported here next fiscal. HICPS includes administrative services and programs, technical support and automated information management systems used to process and pay claims in accordance with NIHB program client/benefit eligibility and pricing policies.

Since 1990, the NIHB program has retained the services of a private sector contractor to administer the following core claims processing services on its behalf:

• claim processing and payment operations
• claim adjudication and reporting systems development and maintenance
• provider registration and communications
• provider audit programs and audit recoveries and
• standard and ad hoc reporting.

The current HICPS contract is with Express Scripts Canada. This contract came into force on June 28, 2020, following a competitive contracting process led by Public Services and Procurement Canada (PSPC). The NIHB program manages the HICPS contract as the project authority in conjunction with PSPC, the contract authority.

As of March 31, 2021, there were 26,173 active* pharmacy, dental or MS&E providers registered with the HICPS claims processor to deliver NIHB benefits. The number of active providers by region and by benefit is outlined in the table below.

* An active provider refers to a provider who has submitted at least one claim in the 24 months prior to March 31, 2021.

NIHB Drug benefit listing and review

The NIHB Drug Benefits List (DBL) is a listing of all of the drugs provided as benefits by the NIHB program. Drugs considered for, or currently listed on, the DBL must meet established criteria. For example, they must be legally available for sale in Canada with a Notice of Compliance (NOC) and Drug Identification Number (DIN) or Natural Product Number (NPN), and be dispensed in a pharmacy. The drugs must also demonstrate evidence of therapeutic efficacy, safety, and incremental benefit in proportion to incremental cost.

The review process for drug products that are considered for inclusion as a benefit under the NIHB program varies depending on the type of drug submitted. Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications, must be sent to the Canadian Agency for Drugs and Technologies in Health (CADTH), an independent organization that provides research and information about the effectiveness of drugs and other medical treatments.

Through the Common Drug Review (CDR) and pan-Canadian Oncology Drug Review (pCODR) processes, CADTH conducts objective evaluations of the clinical, economic, and patient evidence on drugs and medical technologies. Based on this information, the CADTH expert committees provide coverage recommendations and advice to Canada's public drug plans, including the NIHB program. The CDR and pCODR were established by federal, provincial and territorial public drug plans to reduce duplication of effort in reviewing drug submissions, to maximize the use of resources and expertise, and to enhance the consistency and quality of drug reviews.

NIHB Drugs and Therapeutics Advisory Committee (DTAC)

The NIHB DTAC is an advisory body of highly qualified health professionals who bring impartial and practical expert medical and pharmaceutical advice to the NIHB program to promote improvement in the health outcomes of First Nations and Inuit clients through effective use of pharmaceuticals. The approach is evidence-based and the advice reflects medical and scientific knowledge, current utilization trends, current clinical practice, health care delivery and client healthcare needs.

More information on DTAC and its members can be found on the Government of Canada's website at Drugs and Therapeutics Advisory Committee

NIHB Oral Health Advisory Committee (NOHAC)

The NIHB Oral Health Advisory Committee (NOHAC) is an independent advisory body of highly qualified oral health professionals and academic specialists. They bring impartial and practical expert views, advice, and recommendations to the NIHB program to support the improvement of oral health outcomes for First Nations and Inuit clients. The advice and recommendations provided by the Committee follow an evidence-based approach and reflect scientific knowledge, as well as clinical and oral health care delivery and disease prevention best practices.

More information on NOHAC and its members can be found on the Government of Canada's website at The Non-Insured Health Benefits (NIHB) Oral Health Advisory Committee

Drug Exception Centre (DEC)

The Drug Exception Centre is a call centre that provides efficient responses to all requests for drugs that are not on the NIHB Drug Benefit List or require prior approval, for extemporaneous mixtures containing exception or Limited Use (LU) drugs, for prescriptions on which prescribers have indicated "no substitution," and for claims that exceed $1,999.99. The table below shows the volume of requests made to the DEC in 2020 to 2021 by benefit listing type.

Dental Predetermination Centre

The Dental Predetermination Centre (DPC) is a call centre that provides efficient adjudication of all dental and orthodontic predetermination, post-determination and appeals. In addition, the DPC is responsible for addressing client and provider inquiries, and to assist clients and providers with the submission of the predetermination, post-determination, client reimbursement and appeal requests.

Medical Supplies and Equipment Review Centre

NIHB staff at the regional level manage prior approval of medical supplies and equipment benefit requests, with support from the MS&E Review Centre (MSERC) at the NIHB national office. The MSERC is staffed in-house by various health professionals, including registered nurses. In cases where advice is required by a particular specialist, such as an audiologist or an orthotist, information is forwarded to the appropriate specialist consultant for review. Consultants make their recommendations based upon the current standards of practice, best practices, current scientific evidence, program policy and recommended guidelines within their field of specialty.

Client and provider communications

NIHB is continually seeking ways to improve communications with clients, providers and partners regarding benefit coverage and administration.

The NIHB program regularly produces newsletters and updates to inform clients and providers about any changes to NIHB policy and benefit coverage. For example, NIHB enrolled providers for dental, pharmacy, MS&E, vision care and mental health counselling receive notification of policy updates and relevant information regarding benefits through regular provider newsletters, periodic bulletins and broadcast messages.

These communications are distributed to enrolled providers by Express Scripts Canada (ESC), Indigenous Services Canada's claims processing contractor, and are available via the ESC website at: nihb.express-scripts.ca.

The NIHB website is a key venue for disseminating program information to clients. NIHB program updates are produced quarterly and as needed to provide information for clients regarding changes to benefit coverage. They can be found on the Canada.ca website at: Non-Insured Health Benefits program updates. Clients can subscribe to receive email notifications when these updates are published, and those who have set up web accounts through Express Scripts Canada also receive notification of new updates. Client-focused communications are also promoted through social media on the Government of Canada's Healthy First Nations and Inuit Facebook Page and GCIndigenous Twitter account. Additional social media posts promote client awareness of benefit coverage, often in conjunction with broader public health promotion campaigns. For example, a post on diabetes awareness will include a reminder about NIHB coverage of diabetes medications and supplies, and a post on vision health may include a reminder about NIHB coverage of eye exams.

NIHB strives to be accessible and responsive to clients. Clients can contact NIHB directly by calling Indigenous Services Canada regional offices, the NIHB Dental Predetermination Centre, or the NIHB Drug Exception Centre. The "Contact Us" web page for the NIHB program also provides an email address for direct inquiries to the NIHB program.

NIHB Navigators

NIHB Navigators help eligible clients to navigate and access the NIHB program. They are a resource for communities, organizations or individuals who need support or information on NIHB-related issues. Navigators are employed by regional First Nations and Inuit organizations. Their roles and activities are adapted to meet regional needs, and generally include the following:

• increase understanding of the NIHB program and share information on eligible benefits
• help clients and communities to resolve NIHB-related issues
• link with health departments and agencies to help improve client access to NIHB benefits and related health services.

Collaboration with First Nations and Inuit partners

In 2014, the Government of Canada agreed to undertake a multi-year Joint Review of the NIHB program in partnership with the Assembly of First Nations (AFN). The overall objective of the review is to identify and implement actions that enhance client access to benefits, identify gaps in benefits, streamline service delivery to be more responsive to client needs, and increase program efficiencies. The Joint Review is guided by a Steering Committee comprised of First Nations and ISC representatives.

As part of this process, the AFN conducted a robust program of client, provider and stakeholder engagement activities to gather broad input and perspectives that will inform recommendations for program improvements.

Indigenous Services Canada continues to work with Inuit representatives through the Inuit NIHB Senior Bilateral Committee (INSBC) to identify and address areas of concern and recommendations to improve the quality, access, and delivery of NIHB benefits to Inuit clients. NIHB updates Inuit partners regularly on progress made to advance INSBC priority issues, including working towards the implementation of NIHB Navigator positions for Inuit clients in Nunavut and the Inuvialuit Settlement Region.

Population data

First Nations and Inuit population data are drawn from the Status Verification System (SVS) which is operated by NIHB. SVS data on First Nations clients are based on information provided by Indigenous Services Canada (ISC). SVS data on Inuit clients are based on information provided by the Governments of the Northwest Territories and Nunavut, and Inuit organizations including the Inuvialuit Regional Corporation, Nunavut Tunngavik Incorporated and the Makivik Corporation.

Pharmacy, MS&E and dental data

Two Indigenous Services Canada data systems provide information on the expenditures and utilization of the NIHB pharmacy, MS&E and dental benefits. Financial Services and Training (FST) is the source of most of the expenditures data, while the Health Information and Claims Processing Services (HICPS) system provides detailed information on the utilization of the pharmacy, MS&E and dental benefit areas. Expenditure data prior to fiscal year 2019 to 2020 were collected from the Framework for Integrated Resource Management System (FIRMS).

Medical transportation data

Medical transportation financial data are provided through FST. Medical transportation data are also collected regionally through other electronic systems. Operational data at the regional level are tracked through the Medical Transportation Reporting System (MTRS). Contribution agreement data are also collected, but in a limited manner. In some communities, MTRS is used to collect contribution agreement data, while other communities report data using spreadsheet templates, in-house data management systems, or through paper reports.

The Medical Transportation Data Store (MTDS) serves as a repository for selected operational data, as well as the data collected from medical transportation contribution agreements, and ambulance data systems. The objective of the MTDS is to enable aggregate reporting on medical transportation at a national level in order to further strengthen program management, provide enhanced data analysis and reporting and aid in decision making.

Vision care and mental health counselling data

Financial data on the NIHB vision care, mental health counselling are provided through FST.