2013 Spring Report of the Auditor General of Canada Chapter 5—Promoting Diabetes Prevention and Control

2013 Spring Report of the Auditor General of Canada

Chapter 5—Promoting Diabetes Prevention and Control

Main Points

Introduction

The current approach to chronic diseases
Diabetes in Aboriginal peoples
Partners in prevention and control
Diabetes Policy Review
Focus of the audit

Observations and Recommendations

Developing an approach

The Agency does not have a strategy in place for chronic diseases, including diabetes
The Agency has weak management practices in place for delivering diabetes activities
Partnerships needed to deliver on commitments are only partly in place

Enhancing diabetes surveillance

Diabetes surveillance has improved and is well established
Two major gaps in diabetes surveillance persist

Increasing awareness

The Agency has not defined its public information role
Lessons learned from community-based diabetes projects funded by the Agency have not been identified or shared
Health portfolio organizations have not worked together to identify needed diabetes research

Addressing diabetes in Aboriginal communities

Information on the results of the Aboriginal Diabetes Initiative is limited

Conclusion

About the Audit

Appendix—List of recommendations

Exhibits:

5.1—Diabetes in Canada—Facts and Figures

5.2—Current federal approach to chronic disease prevention and control

5.3—The prevalence of self-reported diabetes among Aboriginal peoples aged 12 years and older is higher than in the non-Aboriginal population in Canada

5.4—Partners in promoting diabetes prevention and control

5.5—Key findings and recommendations of the 2008 Diabetes Policy Review

5.6—Partners have pursued surveillance initiatives but have done so separately

5.7—The CANRISK tool helps people assess their risk for diabetes

5.8—Most diabetes community-based projects have a low dollar value

5.9—The Aboriginal Diabetes Initiative funded a range of diabetes prevention and health promotion activities in the 2010–11 fiscal year

 

Performance audit reports

This report presents the results of a performance audit conducted by the Office of the Auditor General of Canada under the authority of the Auditor General Act.

A performance audit is an independent, objective, and systematic assessment of how well government is managing its activities, responsibilities, and resources. Audit topics are selected based on their significance. While the Office may comment on policy implementation in a performance audit, it does not comment on the merits of a policy.

Performance audits are planned, performed, and reported in accordance with professional auditing standards and Office policies. They are conducted by qualified auditors who

Performance audits contribute to a public service that is ethical and effective and a government that is accountable to Parliament and Canadians.

Main Points

What we examined

Diabetes is a chronic condition that occurs when the body cannot sufficiently produce or properly use insulin to absorb sugar. In recognition of the increasing burden of diabetes in Canada, the federal government in 1999 announced the creation of the Canadian Diabetes Strategy. The objectives of the Canadian Diabetes Strategy were to be the prevention, early detection, and self-management of diabetes and its complications; and national surveillance. At the same time, the government identified diabetes prevention and control among Aboriginal populations as a focus of the Canadian Diabetes Strategy, in recognition of the increasing burden of diabetes in this population.

In 2005, the federal government renewed its funding for the Canadian Diabetes Strategy to implement a pan-Canadian approach to diabetes, and provided funding of $18 million per year to the Public Health Agency of Canada to do it. The Agency, Health Canada, and the Canadian Institutes of Health Research were to be key federal players in delivering the approach. Partners were also to include the provinces and territories and various diabetes stakeholder groups across the country. The provinces and territories are primarily responsible for delivering health care programs and services, while the federal government is to act as a catalyst to both lead and support activities aimed at chronic disease prevention and control, including diabetes.

Also in 2005, diabetes activities for Aboriginal populations were separated from the Canadian Diabetes Strategy and established under the Aboriginal Diabetes Initiative within Health Canada. The Department received annual funding which reached $55 million in the 2010–11 fiscal year for the initiative. The government required that linkages be made between the Canadian Diabetes Strategy and the Aboriginal Diabetes Initiative, particularly in the areas of surveillance and national coordination.

The Canadian Institutes of Health Research is the federal health research arm. It funded nearly $44 million in diabetes research in the 2010–11 fiscal year. Through consultations, including with its health portfolio partners, it is responsible for identifying research gaps and prioritizing the funding of research to fill these gaps. It then helps facilitate the use of the results of the research by Canadians.

We examined how the Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research have implemented and coordinated activities with their partners in diabetes prevention and control.

Audit work for this chapter was completed on 28 February 2013. Details on the conduct of the audit are in About the Audit at the end of this chapter.

Why it’s important

Diabetes is a chronic disease that is rapidly growing in Canada. According to the Public Health Agency of Canada, the prevalence of diabetes among Canadians increased by 70 percent from 1999 to 2009. Almost 2.4 million Canadians live with diabetes, and it is estimated that about 20 percent of diabetes cases remain undiagnosed. Compared with individuals who do not have diabetes, those with the disease are over 3 times more likely to be hospitalized with cardiovascular disease, 12 times more likely to be hospitalized with end-stage renal disease, and almost 20 times more likely to be hospitalized for lower limb amputations. The Public Health Agency reported that health care costs are three to four times greater for individuals with diabetes.

The prevalence of diabetes among First Nations is estimated to be two to three times higher than in the general Canadian population. Health Canada funds a wide range of programs for diabetes prevention, screening, and management in more than 600 First Nations communities across the country.

What we found

The entities have responded. The entities agree with all of our recommendations. Their detailed responses follow the recommendations throughout the chapter.

Introduction

5.1 Chronic diseases present one of the biggest challenges facing health care providers, contributing to a significant portion of Canada’s health care costs. In recent years, chronic diseases—including cancer, cardiovascular disease, chronic respiratory disease, and diabetes—have affected a growing number of Canadians. To avoid or delay the costly implications of these diseases will require a multi-strategy approach to prevention and control, one that incorporates policy development and targeted activities to raise awareness and change behaviours. Many chronic diseases share the same modifiable risk factors, including smoking, alcohol misuse, physical inactivity, and unhealthy eating. Stakeholders within and outside the health sector can be engaged in chronic disease prevention and control.

5.2 Diabetes is a serious chronic disease that occurs when the body is unable to sufficiently produce or properly use insulin to absorb sugar. From 1999 to 2009, the prevalence of diabetes among Canadians increased by 70 percent, and the disease is increasingly affecting people at younger ages. Excess weight, obesity in particular, is the most important risk factor for type 2 diabetes and its complications. Almost 2.4 million Canadians (6.8 percent) live with diabetes, and it is estimated that about 20 percent of cases remain undiagnosed. (See Exhibit 5.1 for more details on diabetes.) While it is difficult to assess the real economic burden of diabetes, the Public Health Agency of Canada reported that health care costs are three to four times greater for people with diabetes than for those without it.

Exhibit 5.1—Diabetes in Canada—Facts and Figures

Type 1 diabetes

Type 2 diabetes

Gestational diabetes

Pre-diabetes

Complications

Source: Adapted from Diabetes in Canada, Public Health Agency of Canada, 2011.

The current approach to chronic diseases

5.3 In recognition of the increasing burden of diabetes in Canada, the federal government in 1999 announced its intention to create a Canadian Diabetes Strategy “to enable Canadians to benefit more fully from the considerable resources and expertise available across the country concerning this disease.” Partners in the strategy were to include the provinces and territories, various national health bodies and stakeholder groups, and Aboriginal organizations. Following the announcement, Health Canada led consultations with its partners to identify key priorities for a diabetes strategy. At the same time, the Department put in place programs for diabetes prevention and control directed toward Aboriginal peoples and established a national diabetes surveillance system (which the Public Health Agency of Canada inherited when it was created in 2004). Health Canada also funded projects to increase diabetes awareness in Aboriginal communities across Canada.

5.4 In 2005, the government invested in a new approach to promoting healthy living and preventing and controlling chronic diseases. The approach was designed to achieve three objectives:

The basic principle of this new approach was that initiatives that addressed risk factors common to chronic diseases, such as obesity and physical inactivity, would be balanced by complementary disease-specific investments for cardiovascular disease, cancer, and diabetes. The approach was to be adaptable to new knowledge and opportunities. For more information on the new approach to chronic disease, see Exhibit 5.2.

Exhibit 5.2—Current federal approach to chronic disease prevention and control

Healthy living and prevention of chronic disease

Health promotion—Promoting health by addressing the modifiable conditions common to chronic diseases, such as unhealthy eating, physical inactivity, and unhealthy weights. This includes promoting the health of children in schools and bringing provinces, territories, and stakeholder partners together to develop approaches.

Activities—Activities are to be undertaken by partners across many sectors. The Agency has a role to play in the leadership, engagement, coordination, and development of actions that provide support at the national and international levels, for example working with other federal government sectors and other countries.

Policies—Key policies include the federal–provincial/territorial Declaration on Prevention and Promotion entitled Creating a Healthier Canada: Making Prevention a Priority (2010) and Curbing Childhood Obesity: A Federal, Provincial and Territorial Framework for Action to Promote Healthy Weights (2010).

Complementary efforts

Disease-specific prevention and control

Canadian Strategy for Cancer Control (2006) led by the Canadian Partnership Against Cancer, an independent organization funded by the federal government.

National Lung Health Framework (2008) led by the Canadian Lung Association with time-limited financial federal funding.

Canadian Heart Health Strategy and Action Plan (2009) led by an independent, stakeholder-led steering committee with funding from the Agency.

National Mental Health Strategy (2012) led by the Mental Health Commission of Canada, a non-profit organization funded by the federal government.

Canadian Diabetes Strategy led by the Public Health Agency of Canada.

Source: Adapted from the Public Health Agency of Canada

5.5 The Public Health Agency of Canada was designated as the federal lead for carrying out this new approach. It was allocated $70 million annually, including $18 million for the Canadian Diabetes Strategy. Activities funded for diabetes prevention and control include providing information and expertise to target audiences and expanding surveillance and community-based programs to raise awareness and to change unhealthy behaviours. Engaging the right stakeholders at the right time was seen as a crucial initial outcome if the desired results were to be achieved.

5.6 Since 2005, public health evidence has demonstrated the need to reverse growing obesity rates to reduce the prevalence of major chronic diseases, including type 2 diabetes. This evidence led to agreements among federal, provincial, and territorial ministers of health in 2010 to focus on the prevention of chronic diseases and to address childhood obesity as a priority. This direction was consistent with that of international partners and health organizations. In 2011, Canada endorsed a United Nations declaration that emphasized the need to focus on risk factors, including obesity, for the prevention of chronic disease. The declaration also emphasized the need to engage partners beyond the health sector in finding solutions.

Diabetes in Aboriginal peoples

5.7 Diabetes continues to disproportionately affect Aboriginal peoples, a population considered at high risk of developing the disease and of suffering from its complications. The predominant form of diabetes among First Nations and Métis is type 2. The prevalence of diabetes among First Nations is estimated to be two to three times higher than in the general Canadian population (Exhibit 5.3). Aboriginal peoples diagnosed with type 2 diabetes are younger and have higher rates of complications from the disease, including blindness, high blood pressure, kidney disease, and lower limb amputations. In addition to the common risk factors of unhealthy eating, physical inactivity, smoking, and alcohol misuse, the higher rates of adverse health outcomes in Aboriginal peoples are associated with factors such as low income, lack of education, high unemployment, poor living conditions, and poor access to health services.

Exhibit 5.3—The prevalence of self-reported diabetes among Aboriginal peoples aged 12 years and older is higher than in the non-Aboriginal population in Canada

Bar chart comparing the prevalence of diabetes among Aboriginal and non-Aboriginal populations in Canada

[Exhibit 5.3—text version]

Notes: Diabetes prevalence includes type 1 and type 2. Gestational diabetes is also included for Inuit. The percentages in the exhibit are based on information from different data sources covering time periods ranging from 2006 to the 2009–10 fiscal year. Because different data sources are used, different ages are captured: aged 18+ for First Nations on-reserve; aged 15+ for Inuit; and aged 12+ for First Nations off-reserve, Métis, and the non-Aboriginal population.

Source: Public Health Agency of Canada, Diabetes in Canada, 2011.

5.8 Diabetes prevention and control among Aboriginal peoples were a focus of the original Canadian Diabetes Strategy proposed in 1999. Starting in 2005, the Aboriginal Diabetes Initiative (ADI) was funded separately under Health Canada. The amount allocated to the ADI varied over time and reached a maximum of $55 million in the 2010–11 fiscal year. The ADI supports diabetes programs in more than 600 communities through contribution agreements for the prevention, screening, and management of diabetes. The government required that the ADI continue to be linked to the pan-Canadian approach to diabetes, particularly in the areas of surveillance and national coordination.

Partners in prevention and control

5.9 The coordination of diabetes efforts across federal organizations and collaboration with the provinces, territories, and stakeholder groups is central to the success of these efforts (Exhibit 5.4).

Exhibit 5.4—Partners in promoting diabetes prevention and control

Organization Responsibility

Public Health Agency of Canada

  • Leads the development of a pan-Canadian approach to diabetes.
  • Provides surveillance and information on effective practices for preventing and controlling diabetes, and funds community-based interventions.
  • Receives funding of $18 million annually for the delivery of the Canadian Diabetes Strategy, including $6 million for grants and contributions.

Health Canada

  • Through the Aboriginal Diabetes Initiative, works in partnership with First Nations and Inuit communities and other key stakeholders to disseminate best practices and support the delivery of activities and services for health promotion, primary prevention, and screening and management.
  • Receives annual funding, which reached $55 million in the 2010–11 fiscal year to deliver the Aboriginal Diabetes Initiative.
  • Ensures the integration of nutrition considerations into the Agency’s approach to chronic illness.

Canadian Institutes of Health Research

  • Directs health research funding for the federal government.
  • Funded nearly $44 million in diabetes research in the 2010–11 fiscal year.
  • Funds research in diabetes through the Institute of Nutrition, Metabolism, and Diabetes, as well as the Institute of Aboriginal Peoples’ Health and its open granting programs.

Provincial and territorial governments

  • Act as primary providers of health care under the Constitution.
  • Share responsibility for public health.

Diabetes stakeholders

  • Include organizations with expertise in diabetes and research from national, international, regional, provincial, and territorial governments; academics; health care professionals; and other diabetes experts.
  • Are important to the Agency to deliver its chronic disease prevention programs, including its surveillance, public information, and community-based programs.
Diabetes Policy Review

5.10 In October 2006, the Minister of Health announced a review of the Agency’s progress in developing a pan-Canadian approach to diabetes. A report issued in June 2008 made a number of recommendations for improvement (Exhibit 5.5). Diabetes screening and self-management were highlighted as areas for immediate focus. The Agency took action on some recommendations but never publicly endorsed the report or formally accepted all of its recommendations.

Exhibit 5.5—Key findings and recommendations of the 2008 Diabetes Policy Review

Developing an approach

Enhancing surveillance

Increasing awareness

Focus of the audit

5.11 The focus of our audit was to determine whether the Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research have implemented and coordinated activities, with partners, for the prevention and control of diabetes.

5.12 To make this determination, we examined whether these organizations had

5.13 The audit covered the period from October 2005, when the current approach on chronic diseases was launched, to September 2012. The audit did not examine the delivery of primary care for diabetes. More details about the audit objective, scope, approach, and criteria are in About the Audit at the end of this chapter.

Observations and Recommendations

Developing an approach

5.14 Under the new approach to chronic diseases, the Public Health Agency of Canada has received $18 million a year in funding for the renewal of the Canadian Diabetes Strategy, starting in 2005. This renewal was to include implementing and coordinating activities with the Agency’s partners for the prevention and control of diabetes. The Strategy was to target diabetes investments to those at high risk of developing the disease as well as to those suffering from its complications. The Agency was to coordinate these activities with its key federal partners, Health Canada, and the Canadian Institutes of Health Research, as well as with the provinces, territories, and stakeholder groups such as health professionals, diabetes experts, and interest groups. Working with partners was recognized as critical to the success of this initiative and would maximize the impact of the dollars and efforts invested.

The Agency does not have a strategy in place for chronic diseases, including diabetes

5.15 We examined whether the Agency has established a strategy with its partners to implement and coordinate activities for diabetes prevention and control. We found that a national approach to diabetes has not been established. In 2006, federal, provincial, and territorial governments agreed to focus their efforts on addressing risk factors common to chronic diseases, rather than on developing specific strategies for each chronic disease, such as diabetes.

5.16 Consistent with other jurisdictions and policy directions from the federal, provincial, and territorial ministers of health, the Agency has focused its efforts on addressing the risk factors for major chronic diseases—for example, unhealthy eating. In 2010, the federal, provincial, and territorial ministers of health issued the Declaration on Prevention and Promotion, which emphasizes the need to work together to strengthen and support chronic disease prevention in Canada. In 2010, the Agency, in partnership with the provinces and territories, issued a framework on childhood obesity that includes priorities and targets to promote healthy weight in children. Agency officials indicated that their focus on prevention of childhood obesity is consistent with public health evidence that excess weight and obesity are the main drivers of type 2 diabetes. At the time of our audit, the Agency was working with its provincial and territorial counterparts to put in place priorities and indicators for monitoring childhood obesity rates.

5.17 In addition to focusing on risk factors for major chronic diseases, the Agency is responsible for delivering programs and activities under the Canadian Diabetes Strategy, such as surveillance, community-based programs, and public information. We found that the Agency has not established priorities, deliverables, timelines, performance measures, and expected results in order to guide these activities and track progress. We noted that strategies and action plans are in place for other chronic diseases, such as cardiovascular disease and cancer, and are led by independent organizations (Exhibit 5.2).

5.18 Further, after seven years, the Agency still does not have a strategic plan in place outlining its approach to chronic diseases. For example, it has not clarified which activities it will carry out to address chronic disease risk factors, such as adult obesity, smoking, and alcohol misuse, and how these activities will contribute to its overall approach to prevention and control. In 2010, an internal audit report recommended that the Agency develop a strategic plan and the specific activities it will undertake to achieve its goals. The Agency committed to implementing that recommendation. We noted that in January 2013, after the end of the period under examination by our audit, the Agency had prepared a draft strategic plan for chronic disease prevention.

The Agency has weak management practices in place for delivering diabetes activities

5.19 As part of its 2005 commitments, the Agency was to implement its diabetes prevention and control activities in a coordinated manner within its approach to chronic diseases. We examined the mechanisms in place to coordinate the Agency’s diabetes activities and found that little has been done to set the direction for how activities would work to support each other. Further, we found that the Agency has weak management practices in place for delivering its diabetes prevention and control activities; for example, it has no strategy, priorities, deliverables, or timelines (as we noted in paragraph 5.17), and no performance measures. Our recommendation for the following findings is in paragraph 5.31.

5.20 Internal coordination. The Agency’s internal activities for diabetes prevention and control, such as surveillance, community-based projects, and public information, have to work together to be effective. The Agency was to have established ways to coordinate these activities but has not done so. As a result, its activities are not working together as intended. For example, it is not clear how information obtained through diabetes surveillance is used to guide the content of public information or to target and evaluate community-based projects and thereby maximize their effectiveness.

5.21 Performance measurement and financial tracking. Since receiving funding in 2005, the Agency has been developing performance measures for key activities related to diabetes, including its surveillance and community-based projects. Weaknesses in the Agency’s performance measures were raised in the 2008 Diabetes Policy Review requested by the Minister of Health, as well as in previous internal evaluations, reviews, and audits. The Agency has repeatedly made commitments to develop indicators to track progress and outcomes. While the Agency has made some progress, we found that, seven years after the renewal of funding, it still has not developed measureable outcomes. Without them, it is unclear what success would look like and what progress has been made.

5.22 Under its commitments to Treasury Board, the Agency is required to track the $18 million budgeted annually for diabetes activities, but we found that the Agency has not done so because of limitations in the financial codes used to capture its spending. These problems were also raised in a 2010 internal audit, and the Agency committed to working to ensure the effective monitoring and reporting of expenditures. However, the measures it put in place did not fully resolve the problem, and we found that the Agency is still not accurately tracking dollars spent on its diabetes programs. As a result, we were unable to confirm the resources spent on diabetes programs.

5.23 Reporting. As a condition for its 2005 funding, the Agency was to report to Cabinet in 2009 on its progress in implementing its approach to chronic diseases, including the development of a national Canadian Diabetes Strategy, and on lessons learned. We found that the Agency has not done so. In our opinion, the Agency does not have the plans, performance measures, or financial tracking in place to assess its progress on commitments or to evaluate the impact of its approach, which would be required for proper reporting to Cabinet.

Partnerships needed to deliver on commitments are only partly in place

5.24 As part of the government funding in 2005, the Agency committed to coordinating activities with its partners for the prevention and control of diabetes. Indeed, the federal government stressed the importance of working with federal, provincial, and territorial governments as well as with stakeholder groups to deliver diabetes activities and to make the most of the efforts and dollars invested. We examined whether mechanisms were in place to lead and coordinate federal efforts across the health portfolio and to engage stakeholders in diabetes prevention and control. Our recommendation for the following findings is in paragraph 5.31.

5.25 Federal partners. We found that the Agency has not defined how it will work with its federal partners to carry out and coordinate diabetes activities. We also found that there are no regular mechanisms established to share information or to coordinate diabetes-related activities within the federal health portfolio, as the Agency committed to doing. For example, the Agency aims to deliver evidence-based diabetes policies and programs, but it has established no mechanism for collaborating regularly with the Canadian Institutes of Health Research on defining their research needs. The committee that was set up in 2007 to promote a portfolio approach to policy development, including research, among these federal partners has not met since 2011.

5.26 Provincial and territorial partners. While the Agency has not worked with the provinces and territories to promote a national approach to diabetes, it has worked to further some activities related to diabetes, such as surveillance and childhood obesity, including the Curbing Childhood Obesity Framework. The Agency also works with its provincial and territorial counterparts on health issues through the Public Health Network, which the Agency co-chairs. The Agency has participated in the work of the Public Health Network to support healthy weights and to address childhood obesity. It has also worked with its provincial and territorial counterparts to improve diabetes surveillance.

5.27 Other stakeholders. We found that the Agency has not regularly engaged stakeholders or diabetes experts to set its priorities. In 2005, the Agency committed to creating an external steering committee of diabetes experts to provide general direction and recommend priorities for action. This was not done, and in 2008, the Diabetes Policy Review found little involvement of stakeholders, in particular non-governmental organizations, and pointed out the need for greater partnership with stakeholders in implementing the diabetes strategy.

5.28 In 2010, the Agency created the Diabetes Partnership to consult with stakeholders and obtain their advice on priorities for action. At that time, stakeholders advised that diabetes self-management should be a key area of focus. However, the Agency has not defined how it will address this recommendation. Since its initial meeting in 2010, we found that the Diabetes Partnership has not advised it on diabetes issues as intended.

5.29 Agency officials told us that, consistent with the policy focus on obesity as the main risk factor for type 2 diabetes, the Agency is also working with organizations beyond the health sector to implement the Curbing Childhood Obesity Framework. For example, a summit on healthy weights was held in February 2012 and brought together partners from sectors beyond health.

5.30 The Agency has recognized that strategic partnerships with its stakeholders are a key success factor, and it has worked with some expert groups and external partners on recent initiatives, such as the update to diabetes care guidelines, the delivery of diabetes diagnostic tools, and related efforts to address childhood obesity. However, the Agency has not defined what diabetes partnerships are needed and how to best engage them, nor has it established the mechanisms needed to advance these partnerships to maximize the impact of their efforts and dollars invested. In our view, this has significantly limited the Agency’s ability to deliver programs in collaboration with stakeholder groups, as intended by the government.

5.31 Recommendation. The Public Health Agency of Canada should establish priorities and performance measures and improve financial tracking to assess results achieved by its diabetes activities, under its approach to chronic diseases. In doing this, it should collaborate with its partners, including other members of the health portfolio, and with stakeholder groups to maximize the impact of efforts and dollars invested.

The Agency’s response. Agreed. Canadians who are overweight or obese are at higher risk for developing the most common type of diabetes (type 2 diabetes). One in three Canadian children is overweight or obese. We have put a priority on working with partners to help Canadians achieve healthy weights. Our 2013 plan on chronic disease prevention is the roadmap that describes our chronic disease approach. It is available as of 31 March 2013.

Performance measures to demonstrate our impact are being pilot tested now and will be used to report on results by April 2014.

A revised financial tracking process will be in place in the 2013–14 fiscal year to ensure that the money we spend on diabetes is more precisely tracked and reported.

We will continue to use the pan-Canadian Public Health Network to work with provincial and territorial governments. The Agency’s redesigned funding program, launched on 15 February 2013, formally provided the mechanism for collaboration with stakeholders.

The Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research will expand our existing forums currently focused on the Population Health Intervention Research Initiative established in fall 2006, and the Pathways to Health Equity for Aboriginal Peoples established in fall 2012, to more formally work together to maximize our efforts on diabetes for all Canadians.

Enhancing diabetes surveillance

5.32 Systematic and ongoing diabetes surveillance is needed to monitor disease rates and detect changes in the occurrence of the disease and its complications. Surveillance data would allow governments and stakeholder groups to plan, implement, and evaluate their disease prevention and control programs. The Agency’s surveillance system is based on administrative health care data (hospital records, physician billing databases, and insurance registries) provided by the provinces and territories, as well as data collected from Statistics Canada, the Canadian Institute for Health Information, the First Nations Regional Longitudinal Health Survey, practitioners, and academic researchers.

Diabetes surveillance has improved and is well established

5.33 In 2005, the government identified improvements needed in diabetes surveillance, which the Agency committed to implementing in partnership with provinces and territories. At the same time, the Agency committed to measuring the effectiveness of the diabetes surveillance system. We examined whether the Agency has fulfilled these commitments.

5.34 We found that the Agency’s diabetes surveillance system, established in 1999, is currently the most advanced of its systems for tracking chronic diseases. The Agency collects data from the provinces and territories based on data-sharing agreements. Consistent with approaches in other countries, the Public Health Agency of Canada expanded its surveillance activities in 2010 to cover other chronic diseases, such as cardiovascular disease, along with risk factors.

5.35 We also found that the Agency has implemented, with its partners, several of the needed improvements to diabetes surveillance. The Agency now measures diabetes prevalence, incidence, and outcomes for the nation as a whole as well as within each province and territory. This information was reported most recently in 2011 in its publication Diabetes in Canada. The Agency has also increased the number of diabetes indicators it tracks. In our 2002 September Status Report, Chapter 2, Health Canada—National Health Surveillance, we noted that surveillance activities could be expanded to include indicators on complications associated with diabetes in all provinces and territories; we made a recommendation to that effect. We found that the Agency has made satisfactory progress in implementing our recommendation as it relates to diabetes. In collaboration with the provinces and territories, it is now compiling, reviewing, and disseminating nationwide health information on the complications of diabetes.

5.36 We also found that the Agency has worked to improve data quality. Surveillance data collection and dissemination are now based on reporting standards in common with the provinces and territories. In 2009, the Agency created a quality framework for data collection, which it used to test the quality of its diabetes surveillance data in 2010, with positive results. The Agency measured the effectiveness of its diabetes surveillance system. It has sought to determine user needs and has gathered input from partners and the provinces and territories in determining the enhancements needed to its surveillance program.

Two major gaps in diabetes surveillance persist

5.37 In 2005, the Agency and Health Canada committed to taking steps with partners to improve diabetes surveillance for Aboriginal peoples living on and off reserves. Further, the Agency committed to enhancing its surveillance systems to separate diabetes rates by type.

5.38 Surveillance for Aboriginal peoples living on- and off-reserve. We examined what steps the Agency and Health Canada have taken to improve diabetes surveillance for Aboriginal populations. We found that limited surveillance data exists on diabetes among Aboriginal peoples. We also found that Health Canada and the Agency have each pursued initiatives to improve surveillance in isolation from the other (Exhibit 5.6). As a result, efforts to improve diabetes surveillance for Aboriginal peoples have been fragmented, and progress has been limited. We also found limited collaboration between the two organizations toward improving surveillance for this high-risk population. For example, a working group established for this purpose has not been active since 2008.

Exhibit 5.6—Partners have pursued surveillance initiatives but have done so separately

Health Canada, through the Aboriginal Diabetes Initiative, provided about $2 million to the Canadian First Nations Diabetes Clinical Management and Epidemiologic Study from 2007 to 2010. The study assessed the burden and clinical care gaps in diabetes management in 19 First Nations communities across the country.

The study brought to light major gaps in standards of care for First Nations peoples. For example, 61 percent of the 885 diabetic patients included in the study had uncontrolled blood sugar levels, another 65 percent had unhealthy cholesterol, and another 65 percent were not meeting blood pressure goals. Over 50 percent of patients were at higher risk of serious complications, such as chronic kidney disease.

The study pointed out the urgent need for a First Nations–specific surveillance system to monitor rates and inform program development and to target the largest care gaps.

In 2010, Health Canada provided an additional $1 million to develop and test the feasibility of a web-based diabetes surveillance system, in partnership with First Nations communities. The system was successfully piloted in five First Nations communities.

In 2012, Health Canada decided that it would not expand the system to other communities beyond the pilot phase, because it did not want to build disease-specific databases, and because other potential sources of information, such as electronic health records, were under development.

The Agency has signed data-sharing agreements with Métis groups in four provinces totalling $3.6 million over five years. The agreements are meant to improve communities’ ability to engage in chronic disease surveillance activities. However, Agency officials confirmed that there are no plans to extend similar partnerships to other Aboriginal peoples living off-reserve. Therefore, at the present time, only about 36 percent of Canada’s estimated 800,000 Aboriginal peoples living off-reserve are covered by data-sharing agreements. Surveys are used to gather information on remaining populations.

5.39 We found that the Agency and Health Canada have not developed a plan to guide their efforts at improving diabetes surveillance for Aboriginal peoples. Across Canada, many provincial and territorial databases used for diabetes surveillance do not identify Aboriginal peoples, making it a challenge to collect this information nationally. The Agency has used surveys conducted by Statistics Canada and studies to estimate diabetes rates among Aboriginal populations, but the information remains limited. In 2012, Health Canada took initial steps to identify the data it needs for national monitoring and surveillance. The national plan depends on regional surveillance plans, which are at different stages of development. For example, the Atlantic region has a surveillance plan, and it reports estimates of diabetes rates among First Nations living on-reserve.

5.40 In the absence of a surveillance plan and ongoing collaboration to guide their efforts, Health Canada’s and the Agency’s ability to improve diabetes surveillance of Aboriginal populations remains limited.

5.41 Recommendation. The Public Health Agency of Canada and Health Canada should collaborate with First Nations, Métis, Inuit groups, and other partners to develop and implement a plan for the surveillance of diabetes in Aboriginal peoples.

The entities’ response. Agreed. Health Canada and the Public Health Agency of Canada are committed to a practical approach to increase capacity for more robust national diabetes surveillance to report on rates of this illness for all Canadians (for example, type 2 and gestational diabetes), while mitigating challenges in Aboriginal surveillance, including privacy, access to provincial and territorial data, and First Nations data governance.

Health Canada has improved its use of data from communities, provinces and territories, and the Non-Insured Health Benefits program to measure the impact of diabetes in First Nations populations (for example, Alberta and the Atlantic regions produce annual health status reports). Health Canada’s Strategic Plan prioritizes improving data collection, including a national indicators framework. By December 2013, Health Canada will develop a First Nations and Inuit Health surveillance strategy, including diabetes, building on existing regional surveillance initiatives. For its part, the Agency regularly reports on diabetes in Canada and estimates diabetes in Aboriginal populations.

By spring 2014, the Agency and Health Canada will develop a joint surveillance plan with First Nations, Métis, and Inuit partners to enhance diabetes surveillance in Aboriginal peoples, which will be informed by the First Nations and Inuit Health surveillance strategy and the Agency’s diabetes surveillance initiatives. In 2014, partners will collaborate to implement the surveillance plan.

5.42 Identification of diabetes by type. In 2005, the Agency was funded to enhance its diabetes surveillance by identifying diabetes rates by type. The 2008 Diabetes Policy Review also recommended that additional data be collected on the different types of diabetes. As type 1 and type 2 diabetes and gestational diabetes have different risk factors, separate surveillance information is important to guide prevention and control activities. We found that the Agency’s progress in differentiating diabetes by type has been slow.

5.43 The Agency does not yet provide this information nationally, as is done in the United States and Australia. Agency officials told us that the coding system used by the provinces and territories does not allow the Agency to accurately differentiate type 1 and type 2 diabetes at the national level, but that modelling systems could be used to better estimate the rates. In the 2012–13 fiscal year, the Agency funded pilot projects to explore methods for estimating type 1 and type 2 diabetes separately, as well as gestational diabetes.

5.44 Recommendation. The Public Health Agency of Canada should use the funds that it has been allocated to report on the different types of diabetes separately to further guide prevention and control activities.

The Agency’s response. Agreed. The Agency has an effective surveillance system that accurately tracks chronic diseases, including type 2 diabetes. Type 2 is the most common form of diabetes and accounts for 90 to 95 percent of diabetes in Canada. We will continue our regular reporting to Canadians on type 2 diabetes and its risk factors and will release our next update in 2014.

Because of significant technical challenges in identifying gestational and type 1 diabetes through our surveillance system, we have started to use information from surveys of Canadians to estimate these rates. We will assess the feasibility and cost-effectiveness of using other data sources (for example, drug data, hospital data) to improve reporting on type 1 and gestational diabetes by the end of the 2014–15 fiscal year.

Increasing awareness

5.45 A key role assigned to the Public Health Agency of Canada for diabetes prevention and control is providing information and expertise on diabetes prevention and on ways to delay and manage complications of the disease. In 2005, the Agency committed to working with partners to provide target audiences with information on the best approaches, tools, and interventions for diabetes prevention and control.

The Agency has not defined its public information role

5.46 We examined whether the Agency has identified the target audiences, that is, those at high risk of developing the disease or who are currently living with it. We also examined whether the Agency has assessed these audiences’ information needs and developed products to meet those needs. We reviewed the Agency’s website, its primary vehicle for disseminating information.

5.47 We found that the Agency has not identified the diabetes information and expertise that it needs to provide, on its own or with partners. For example, it has identified neither its target audiences and their information needs, nor the most effective means of providing this information. As a result, it has limited means to gauge the success of its efforts at providing diabetes information to target populations. The Agency provides general diabetes information on its website, including

Although we did find a few examples of information products tailored to specific audiences, such as the CANRISK tool (Exhibit 5.7), most information on the website is not specific to high-risk populations, such as certain ethnic groups, and is not specific to age, gender, or diabetes type, as is information provided in other countries.

Exhibit 5.7—The CANRISK tool helps people assess their risk for diabetes

Over the last several years, the Agency has worked with partners, including the provinces, territories, and stakeholders, to adapt and implement a risk assessment questionnaire from Finland for diabetes screening in the Canadian context. Known as CANRISK, this tool is intended for use by adults aged 40 to 74. By answering a series of questions (for example, about age, gender, ethnicity, level of physical activity, and eating habits), an adult can determine if he or she is at low, moderate, or high risk of having pre-diabetes or type 2 diabetes and whether to seek more conclusive diagnostic testing for diabetes and pre-diabetes from a primary care provider.

The Agency has worked with partners to make the tool available at pharmacy counters across Canada and has developed a user guide to help pharmacists review CANRISK results with customers. The general public can also access Your Guide to Diabetes with information on types of diabetes, prevention, and complications. The Agency is currently expanding the reach of CANRISK to high-risk populations by translating the tool into 11 languages. A mobile application has also been developed and is available for free download.

5.48 We also found that the information on the website was limited and dated. For example, information provided on the Canadian Diabetes Strategy is inaccurate and predates the 2005 renewal of funding for the Strategy. Economic analysis of the burden of diabetes has not been updated since 2000, even though the Agency was funded to do so and the 2008 Policy Review recommended that the analysis be updated. Further, several links to other websites did not function.

5.49 Recommendation. The Public Health Agency of Canada, with its partners, should clearly define its public information role and provide targeted information on diabetes prevention and control to address the needs of populations at high risk of developing the disease and its complications.

The Agency’s response. Agreed. We are already working with our partners to develop information on diabetes and on how to avoid its complications (for example, foot care, eye problems). Links to these resources can be found on our website.

By March 2014, we will work with our partners to clarify roles and responsibilities in providing information to Canadians on diabetes, so that stakeholders are clear on the Agency’s priorities in this area. We will increase the sharing of best and promising practices, found through Agency-funded projects, with our partners and stakeholders.

Lessons learned from community-based diabetes projects funded by the Agency have not been identified or shared

5.50 Community-based projects can be an effective way to raise diabetes awareness among populations at risk of developing diabetes, or who are currently living with it, to improve health outcomes. When the Agency received funding in 2005, it committed to delivering community-based programming that is appropriate to the particular needs of the communities, and to evaluate and share the results. The government emphasized the need for the Agency to identify best approaches, tools, and interventions in community-based projects, which would then be shared to advance future projects.

5.51 Of the Agency’s $18 million budget for the Canadian Diabetes Strategy, $6 million is available each year to fund organizations through contribution agreements. These organizations are funded to deliver projects for populations at high risk of diabetes and those who already have diabetes, and to identify lessons learned. We examined whether the Agency has funded community-based projects that are appropriate to the needs of targeted communities. We also examined whether the impact of these projects has been assessed and whether lessons learned have been identified and shared.

5.52 We found that the Agency has not determined how it will best reach high-risk populations, or which types of projects or tools would be most appropriate to invest in. Moreover, it has not identified or shared lessons learned or best approaches in its community-based projects. Most of its funded projects are short term and cover diverse subjects, making it difficult to assess their impact. Most also have a low dollar value—for example, funding for about 80 percent of projects delivered by the Agency’s regional offices in the 2010–11 and 2011–12 fiscal years was below $100,000 (Exhibit 5.8).

Exhibit 5.8—Most diabetes community-based projects have a low dollar value

Bar chart showing the percentage of total agreements at various dollar values for the 2010-11 and 2011-12 fiscal years

[Exhibit 5.8—text version]

5.53 We randomly selected 22 of the 83 community-based projects that were funded by the Agency between April 2009 and March 2012. We found that the Agency’s processes for soliciting and approving these projects took an average of five months to complete; the projects required the approval of the Minister of Health, adding to the burden and delay. We also found that the Agency has no service standards in place for its solicitation and approval processes. We estimated that it cost the Agency’s regional offices $2.44 million to distribute $5.13 million in funding to all its community-based projects over two fiscal years. In other words, it costs the Agency an additional 48 cents to administer every dollar it distributes to communities. The Agency has recognized the need to improve the timeliness of project approvals and to reduce the administrative burden of community-based projects. Despite its repeated commitments to improve the process, the problem persists. At the time of our audit, the Agency was developing service standards to improve the timeliness of its approval process.

5.54 Since 2005, the Agency has had difficulty distributing all funding available each year. For example, in the 2011–12 fiscal year, it committed only 60 percent of available funding to community-based projects. Officials told us that they have had difficulty distributing all the funding available because of their administrative delays and, as indicated by a low response to solicitations, because community and stakeholder groups may not be interested in applying for the types of projects the Agency funds.

5.55 We also found that the Agency has not developed performance measures to capture the results of projects, nor has it identified best approaches, tools, interventions, and lessons learned as was the intent when it received funding. While the Agency has made some progress, such as developing standard reports at project completion in 2010, performance measurement remains weak, and it is unclear what impact has been made. Further, descriptions of funded projects are not available on the Agency’s website. In our opinion, how the program is currently managed hampers the Agency’s ability to make a difference in raising diabetes awareness, and therefore the value of investments in community-based projects is not maximized.

5.56 Recommendation. The Public Health Agency of Canada should rethink its approach to community-based projects to maximize their impact on improving health outcomes of high-risk populations.

The Agency’s response. Agreed. Both the United Nations and Canada’s own Declaration on Prevention and Promotion state that preventing chronic diseases, including diabetes, requires partnerships among the public, private, and voluntary sectors. The Agency is committed to this objective and is successfully launching new partnerships with the public and private sectors. Our approach is getting international attention.

On 15 February 2013, we launched a redesigned funding program. We require organizations to develop partnerships and to show concrete outcomes that can be measured. We have service standards on timelines for review and funding decisions so that projects get under way faster.

Sharing results and lessons learned is a priority. All funded projects are required to share their results publicly with Canadians.

This redesigned program aligns with the Agency’s overall priority of streamlining the delivery of grants and contributions. This includes implementing a smaller administration, service standards, and risk-based reporting by April 2014.

Health portfolio organizations have not worked together to identify needed diabetes research

5.57 As part of its 2005 commitments, the Agency was to identify the research needed to advance diabetes prevention and control activities and was to develop evidence-based diabetes programs, including community-based projects. In 2005, Health Canada committed to doing the same for the Aboriginal Diabetes Initiative, identifying the research needed to guide diabetes activities for Aboriginal peoples and to fund relevant research to meet those needs.

5.58 The Canadian Institutes of Health Research (CIHR) is the federal government’s main funding arm for health research. It is mandated to identify gaps in health-related research, prioritize the funding of those gaps, and help Canadians use the research results. The CIHR identifies research gaps and priorities in consultation with stakeholders, including its partners in the health portfolio. CIHR funded nearly $44 million in diabetes-related research in the 2010–11 fiscal year. It did not receive funding for diabetes research under the Canadian Diabetes Strategy or the Aboriginal Diabetes Initiative. The 2008 Diabetes Policy Review recommended that the Agency set research goals cooperatively and initiate diabetes research in close alliance with the Canadian Institutes of Health Research. As well, Health Canada committed to working with CIHR for research needed to advance the Aboriginal Diabetes Initiative. These federal organizations need to collaborate in order to ensure that diabetes research gaps are identified and considered for funding, and that results are used to benefit Canadians.

5.59 We examined whether the Agency and Health Canada have identified the research needed to support and guide their diabetes programs. Agency officials have stated that they need research that can identify, for example, policy tools to effectively encourage healthy lifestyles, and useful community-based projects that can be introduced or replicated in other communities. We found that the Agency has not yet developed a research plan. Health Canada identified broad research priority areas in 2007, but it has not developed a detailed plan that identifies research priorities, budgets, and timelines; who will do the research; and how it will be shared and used to advance the federal approach to diabetes.

5.60 In 2010, CIHR updated its priorities for diabetes research after consulting extensively with stakeholders, including health portfolio partners. However, because the Agency and Health Canada did not have a research plan, they had limited input when CIHR requested their participation. As mentioned previously, Health Canada established a committee in 2007 to foster a portfolio-wide approach to policy development, including the needed research. That committee has not met since 2011 to collaborate on portfolio-wide policy development and research needs. However, Health Canada and the Agency participate in a CIHR initiative established in fall 2012 to help address the health inequities of First Nations, Inuit, and Métis, with obesity being one priority.

5.61 We found instances when health portfolio partners collaborated to fund diabetes research projects. For example, Health Canada transferred close to $700,000 to CIHR to fund four diabetes-related research projects between 2005 and 2010. From 2010 to 2012, Health Canada collaborated with the Agency to provide $550,000 for research on obesity prevention in Aboriginal peoples. Because this funding did not follow a research plan, there could be missed opportunities for research that would provide evidence to support programs being delivered.

5.62 Like the Agency and Health Canada, CIHR has a mandate to promote the dissemination and application of health research to improve the health of Canadians and provide more effective health services and products. In response to a recent peer review, CIHR started to encourage more dissemination of research results. It developed a policy, effective January 2013, that will require its funded researchers to make their peer-reviewed publications freely accessible to the public within 12 months of publication. It also developed a policy in July 2011 requiring researchers to report on and evaluate the impact of their funded research in an end-of-grant reporting template. At the time of our audit, CIHR was still in the process of determining both the content of these reports and its approach to promoting the sharing of research results.

5.63 Recommendation. The Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research should collaborate to ensure that diabetes research gaps are identified, that the needed research is considered for funding, and that results are used to benefit Canadians.

The entities’ response. Agreed. The Canadian Institutes of Health Research, Health Canada, and the Public Health Agency of Canada will identify diabetes research priorities and gaps on an annual basis, beginning June 2013, for funding consideration.

This work will enhance the current partnership approach that Health Canada, the Public Health Agency of Canada, and the Canadian Institutes of Health Research began, through the Pathways to Health Equity for Aboriginal Peoples Initiative and Population Health Intervention Research, to build evidence on risk factors and prevention of chronic diseases, including diabetes.

Addressing diabetes in Aboriginal communities

5.64 Health Canada’s Aboriginal Diabetes Initiative (ADI) was designed to allow communities to tailor diabetes prevention and control activities to their particular needs. Since 2005, Health Canada has committed to delivering Aboriginal community-based programming for diabetes prevention, screening, and management, and to monitoring and evaluating the results of funded activities. It provides communities with ADI funding through contribution agreements.

Information on the results of the Aboriginal Diabetes Initiative is limited

5.65 Communities are required to prepare plans that outline the diabetes-related activities to be carried out each year with the funding received (Exhibit 5.9) and to complete yearly performance reports outlining the funded activities undertaken. To measure the success and impact of activities funded under the ADI, Health Canada needs performance measures and indicators. Internal evaluations of the program have recommended that performance measurement be strengthened, and the Department committed to doing so.

Exhibit 5.9—The Aboriginal Diabetes Initiative funded a range of diabetes prevention and health promotion activities in the 2010–11 fiscal year

Components of the Aboriginal Diabetes Initiative (ADI) Diabetes activities Budget
($ Millions)

Community-based health promotion and primary prevention

For urban First Nations, Inuit, and Métis, education on nutrition, exercise, as well as participatory sporting events like walking clubs.

$2.0

For First Nations on-reserve and Inuit communities, health promotion and primary prevention projects to increase healthy behaviours and improve diabetes awareness through educational activities.

Includes $2 million for food security and improved access to healthy food, such as through community kitchens and gardens.

$30.6

Screening and management

Awareness and prevention measures, such as screening, regular medical care, and support groups.

Management activities, such as regular blood sugar testing, in order to reduce or delay diabetes-related complications.

$10.0

Capacity building and training

Diabetes care and prevention training for community workers.

$0.8

Diabetes training for health professionals and funding for multi-disciplinary teams, which can provide expertise in nutrition, physical activity, and diabetes.

$5.0

Knowledge mobilization

Undertaken by Health Canada: research, surveillance, communication, and evaluation and monitoring, to support data collection and sharing of knowledge.

$6.6

Total ADI funding

$55 million

Source: Health Canada, Aboriginal Diabetes Initiatives Budget 2010–11. (This data was not audited by the Office of the Auditor of General.)

5.66 We examined 22 files for projects funded by Health Canada in Aboriginal communities to determine the types of activities that were funded under the Aboriginal Diabetes Initiative and how their performance was measured. The files were randomly selected from the 639 projects funded in the 2010–11 and 2011–12 fiscal years, representing total funding of about $6.4 million. We found that a wide range of community-based projects were funded for disease prevention and control, such as healthy eating workshops and physical activity classes, as well as for screening services to diagnose new cases of diabetes or to detect complications such as foot ulcers.

5.67 Health Canada’s ongoing performance measures and indicators for the ADI rely heavily on performance reports submitted annually by communities that receive funding under the initiative. For the 22 files we reviewed, we assessed the performance information provided and how it was used by Health Canada to improve its programming. We found that 21 of the 22 files contained the required performance reports on diabetes prevention and screening activities undertaken. However, we found that Health Canada made limited use of this information to improve its diabetes programming, because the reports were largely activity based and did not allow Health Canada to assess the results of the funded projects. For example, although reports contained information on the number of individuals diagnosed with diabetes, they did not track whether they benefited from funded activities such as foot clinics and community kitchens.

5.68 Health Canada carried out an evaluation of the ADI for the period from 2005 to 2010. Evaluators conducted site visits to 29 of the more than 600 communities and interviewed community health staff, community leaders, Health Canada’s regional staff, key stakeholders, and focus groups. The evaluation found that the ADI has been effective in contributing to individuals’ increased awareness and knowledge of diabetes, healthy eating, and physical activity. The evaluation also found evidence that the ADI has contributed to sustained behavioural changes by some individuals to healthier eating and increased physical activity. However, the evaluation report states that there was limited performance and monitoring data upon which to base the assessment of performance on many of the outcomes. Health Canada’s regional staff indicated that there is limited surveillance and outcome data available for communities, so gathering evidence on effectiveness of activities is difficult.

5.69 In 2005, Health Canada committed to working with its partners and to providing information to Aboriginal communities on the best approaches, tools, and interventions for diabetes prevention and control. We found that the Department has identified promising practices and shared them with communities that receive ADI funding. For example, it is part of a federal–provincial/territorial working group that produced a report outlining promising practices for increasing physical activity among Aboriginal children and youth. Health Canada has also funded the development of an Aboriginal Food Guide to help improve eating habits. While few promising practices are posted on its website, the Department is currently funding the development by the National Aboriginal Diabetes Association of a web-based repository of resources for diabetes, which will include promising practices.

5.70 The identification and sharing of promising practices for diabetes prevention and control can be used to develop effective programming. Performance information and surveillance information can then indicate whether funding has had a positive impact on the community. While improving the surveillance of Aboriginal peoples was a priority of the ADI, limited diabetes surveillance information exists on Aboriginal peoples, as already noted. Performance information available for funded programs is also limited. This lack of information hampers Health Canada’s ability to track the nature and extent of Aboriginal diabetes and to determine the impact of the diabetes programs it promotes and funds for Aboriginal peoples.

5.71 Recommendation. Health Canada, in collaboration with partners, should develop performance measures and use them along with surveillance information to assess and advance the diabetes activities funded under the Aboriginal Diabetes Initiative (ADI).

The Department’s response. Agreed. Health Canada currently has performance measures built into community reporting mechanisms that form part of contribution agreement accountabilities.

Health Canada, in collaboration with First Nations, Inuit, and other partners, will

Conclusion

5.72 The Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research each implemented activities for the prevention and control of diabetes. However, they have not adequately coordinated their activities, which is critical to the success of the Canadian Diabetes Strategy.

5.73 We concluded that, seven years after the renewal of funding, the Agency still does not have a strategy in place to guide its activities related to chronic diseases, including diabetes. Furthermore, its own diabetes activities are not coordinated internally. Little has been done to set the direction for how activities would work to support each other. The Agency has weak management practices in place for delivering these activities. That is, it has not set priorities, performance measures, deliverables, timelines, and expected results for diabetes activities. Ultimately, it does not know whether its activities are having an impact on the well-being of people who live with diabetes or who are at risk of developing the disease.

5.74 The partnerships needed to coordinate the Agency’s delivery on commitments are only partly in place. The Agency established a forum to get advice from diabetes experts, but it has not functioned as intended. The committee created to coordinate activities within the federal health portfolio is no longer active. The Canadian Institutes of Health Research took appropriate steps to coordinate activities in updating priorities for diabetes research by consulting with the Agency and Health Canada. Neither was able to appropriately respond, because they did not have a research plan.

5.75 The Agency has a well-established diabetes surveillance system and has data-sharing agreements with provinces and territories, forming the basis for expanding surveillance to other chronic diseases. The Agency has also measured the effectiveness of the surveillance system. However, Health Canada and the Agency have made little progress on collaborating to improve the limited diabetes surveillance information on Aboriginal peoples. Furthermore, Health Canada gathers limited performance information on the results of its Aboriginal Diabetes Initiative projects. This hampers its ability to track the nature and extent of Aboriginal diabetes and to determine the impact of the diabetes programs it promotes and funds for Aboriginal peoples.

About the Audit

All of the audit work in this chapter was conducted in accordance with the standards for assurance engagements set by The Canadian Institute of Chartered Accountants. While the Office adopts these standards as the minimum requirement for our audits, we also draw upon the standards and practices of other disciplines.

As part of our regular audit process, we obtained management’s confirmation that the findings reported in this chapter are factually based.

Objective

The objective of the audit was to determine whether the Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research have implemented and coordinated activities, with partners, for the prevention and control of diabetes.

Scope and approach

We examined federal activities that have been put in place for diabetes prevention and control, as well as the mechanisms and plans in place to coordinate diabetes activities of the federal health partners, including the Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research. We interviewed officials responsible for the delivery of diabetes activities; analyzed relevant policies, procedures, and expenditures; and visited two regional offices. For the Canadian Diabetes Strategy, we reviewed 22 of 83 files selected at random for contribution agreements funded between April 2009 and March 2012. For the Aboriginal Diabetes Initiative, we reviewed 22 of 639 projects selected at random for contribution agreements funded in the 2010–11 and 2011–12 fiscal years. We reviewed meeting minutes for the Public Health Network and Diabetes Partnership.

Criteria

Criteria Sources
To determine whether the Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research have implemented and coordinated activities, with partners, for the prevention and control of diabetes, we used the following criteria:

The Public Health Agency of Canada, with partners, has established a strategy to implement and coordinate activities for the prevention and control of diabetes.

  • Decision for the Integrated Strategy on Healthy Living and Chronic Disease, Treasury Board, and related Agency submission, 2005

The Public Health Agency of Canada has ensured that diabetes prevention and control activities are implemented and coordinated internally within its Integrated Strategy for Healthy Living and Chronic Disease.

  • Decision for the Integrated Strategy on Healthy Living and Chronic Disease, Treasury Board, and related Agency submission, 2005

The Public Health Agency of Canada, with partners, has implemented improvements needed in diabetes surveillance.

  • Decision for the Integrated Strategy on Healthy Living and Chronic Disease, Treasury Board, and related Agency submission, 2005
  • Public Health Agency of Canada’s Surveillance Strategic Plan, 2007

The Public Health Agency of Canada has measured the effectiveness of the surveillance system that is used to track diabetes.

  • Decision for the Integrated Strategy on Healthy Living and Chronic Disease, Treasury Board, and related Agency submission, 2005
  • Public Health Agency of Canada’s Surveillance Strategic Plan, 2007

The Public Health Agency of Canada has delivered community-based programming that is appropriate to the particular needs of communities, and has evaluated and shared its results.

  • Decision for the Integrated Strategy on Healthy Living and Chronic Disease, Treasury Board, and related Agency submission, 2005
  • Policy on Transfer Payments, Treasury Board

The Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research, with partners, have defined and funded the research needed to guide diabetes prevention and control activities.

  • Decision for the Integrated Strategy on Healthy Living and Chronic Disease, Treasury Board, and related Agency submission, 2005
  • Integrated Strategy on Healthy Living and Chronic Disease, Public Health Agency of Canada, 2005
  • Food and Nutrition Program Strategic Plan 2011–2015, Health Canada
  • Decisions for the Aboriginal Diabetes Initiative, Treasury Board, and related Health Canada and Agency submissions, 2005 and 2010
  • Institute of Nutrition, Metabolism and Diabetes Strategic Plan 2010–2014, Canadian Institutes of Health Research
  • Institute of Aboriginal Peoples’ Health Strategic Plan 2006–2011, Canadian Institutes of Health Research

The Public Health Agency of Canada, with partners, has provided public information to target audiences on the best approaches, tools, and interventions for diabetes prevention and control.

  • Decision for the Integrated Strategy on Healthy Living and Chronic Disease, Treasury Board, and related Agency submission, 2005

The Public Health Agency of Canada and Health Canada, with partners, have taken steps to improve diabetes surveillance for Aboriginal populations.

  • Decisions for the Aboriginal Diabetes Initiative, Treasury Board, and related Health Canada and Agency submissions, 2005 and 2010
  • Decision for the Integrated Strategy on Healthy Living and Chronic Disease, Treasury Board, and related Agency submission, 2005

Health Canada, with partners, has delivered Aboriginal community-based programming for diabetes prevention and control and has monitored and evaluated its results.

  • Decisions for the Aboriginal Diabetes Initiative, Treasury Board, and related Health Canada and Agency submissions, 2005 and 2010
  • Policy on Transfer Payments, Treasury Board

Health Canada, with partners, has provided information to Aboriginal communities on the best approaches, tools, and interventions for diabetes prevention and control.

  • Decisions for the Aboriginal Diabetes Initiative, Treasury Board, and related Health Canada and Agency submissions, 2005 and 2010

Management reviewed and accepted the suitability of the criteria used in the audit.

Period covered by the audit

The audit covered the period between October 2005, when the Integrated Strategy on Healthy Living and Chronic Disease was launched, to September 2012. Audit work for this chapter was completed on 28 February 2013.

Audit team

Assistant Auditor General: Neil Maxwell
Principal: Louise Dubé
Director: Carol McCalla

Sébastien Bureau
Jenna Germaine
Jeff Graham
Hon Lam
Margaretha Ysselstein

For information, please contact Communications at 613-995-3708 or 1-888-761-5953 (toll-free).

Appendix—List of recommendations

The following is a list of recommendations found in Chapter 5. The number in front of the recommendation indicates the paragraph where it appears in the chapter. The numbers in parentheses indicate the paragraphs where the topic is discussed.

Recommendation Response
Developing an approach

5.31 The Public Health Agency of Canada should establish priorities and performance measures and improve financial tracking to assess results achieved by its diabetes activities, under its approach to chronic diseases. In doing this, it should collaborate with its partners, including other members of the health portfolio, and with stakeholder groups to maximize the impact of efforts and dollars invested. (5.14–5.30)

The Agency’s response. Agreed. Canadians who are overweight or obese are at higher risk for developing the most common type of diabetes (type 2 diabetes). One in three Canadian children is overweight or obese. We have put a priority on working with partners to help Canadians achieve healthy weights. Our 2013 plan on chronic disease prevention is the roadmap that describes our chronic disease approach. It is available as of 31 March 2013.

Performance measures to demonstrate our impact are being pilot tested now and will be used to report on results by April 2014.

A revised financial tracking process will be in place in the 2013–14 fiscal year to ensure that the money we spend on diabetes is more precisely tracked and reported.

We will continue to use the pan-Canadian Public Health Network to work with provincial and territorial governments. The Agency’s redesigned funding program, launched on 15 February 2013, formally provided the mechanism for collaboration with stakeholders.

The Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research will expand our existing forums currently focused on the Population Health Intervention Research Initiative established in fall 2006, and the Pathways to Health Equity for Aboriginal Peoples established in fall 2012, to more formally work together to maximize our efforts on diabetes for all Canadians.

Enhancing diabetes surveillance

5.41 The Public Health Agency of Canada and Health Canada should collaborate with First Nations, Métis, Inuit groups, and other partners to develop and implement a plan for the surveillance of diabetes in Aboriginal peoples. (5.37–5.40)

The entities’ response. Agreed. Health Canada and the Public Health Agency of Canada are committed to a practical approach to increase capacity for more robust national diabetes surveillance to report on rates of this illness for all Canadians (for example, type 2 and gestational diabetes), while mitigating challenges in Aboriginal surveillance, including privacy, access to provincial and territorial data, and First Nations data governance.

Health Canada has improved its use of data from communities, provinces and territories, and the Non-Insured Health Benefits program to measure the impact of diabetes in First Nations populations (for example, Alberta and the Atlantic regions produce annual health status reports). Health Canada’s Strategic Plan prioritizes improving data collection, including a national indicators framework. By December 2013, Health Canada will develop a First Nations and Inuit Health surveillance strategy, including diabetes, building on existing regional surveillance initiatives. For its part, the Agency regularly reports on diabetes in Canada and estimates diabetes in Aboriginal populations.

By spring 2014, the Agency and Health Canada will develop a joint surveillance plan with First Nations, Métis, and Inuit partners to enhance diabetes surveillance in Aboriginal peoples, which will be informed by the First Nations and Inuit Health surveillance strategy and the Agency’s diabetes surveillance initiatives. In 2014, partners will collaborate to implement the surveillance plan.

5.44 The Public Health Agency of Canada should use the funds that it has been allocated to report on the different types of diabetes separately to further guide prevention and control activities. (5.42–5.43)

The Agency’s response. Agreed. The Agency has an effective surveillance system that accurately tracks chronic diseases, including type 2 diabetes. Type 2 is the most common form of diabetes and accounts for 90 to 95 percent of diabetes in Canada. We will continue our regular reporting to Canadians on type 2 diabetes and its risk factors and will release our next update in 2014.

Because of significant technical challenges in identifying gestational and type 1 diabetes through our surveillance system, we have started to use information from surveys of Canadians to estimate these rates. We will assess the feasibility and cost-effectiveness of using other data sources (for example, drug data, hospital data) to improve reporting on type 1 and gestational diabetes by the end of the 2014–15 fiscal year.

Increasing awareness

5.49 The Public Health Agency of Canada, with its partners, should clearly define its public information role and provide targeted information on diabetes prevention and control to address the needs of populations at high risk of developing the disease and its complications. (5.45–5.48)

The Agency’s response. Agreed. We are already working with our partners to develop information on diabetes and on how to avoid its complications (for example, foot care, eye problems). Links to these resources can be found on our website.

By March 2014, we will work with our partners to clarify roles and responsibilities in providing information to Canadians on diabetes, so that stakeholders are clear on the Agency’s priorities in this area. We will increase the sharing of best and promising practices, found through Agency-funded projects, with our partners and stakeholders.

5.56 The Public Health Agency of Canada should rethink its approach to community-based projects to maximize their impact on improving health outcomes of high-risk populations. (5.50–5.55)

The Agency’s response. Agreed. Both the United Nations and Canada’s own Declaration on Prevention and Promotion state that preventing chronic diseases, including diabetes, requires partnerships among the public, private, and voluntary sectors. The Agency is committed to this objective and is successfully launching new partnerships with the public and private sectors. Our approach is getting international attention.

On 15 February 2013, we launched a redesigned funding program. We require organizations to develop partnerships and to show concrete outcomes that can be measured. We have service standards on timelines for review and funding decisions so that projects get under way faster.

Sharing results and lessons learned is a priority. All funded projects are required to share their results publicly with Canadians.

This redesigned program aligns with the Agency’s overall priority of streamlining the delivery of grants and contributions. This includes implementing a smaller administration, service standards, and risk-based reporting by April 2014.

5.63 The Public Health Agency of Canada, Health Canada, and the Canadian Institutes of Health Research should collaborate to ensure that diabetes research gaps are identified, that the needed research is considered for funding, and that results are used to benefit Canadians. (5.57–5.62)

The entities’ response. Agreed. The Canadian Institutes of Health Research, Health Canada, and the Public Health Agency of Canada will identify diabetes research priorities and gaps on an annual basis, beginning June 2013, for funding consideration.

This work will enhance the current partnership approach that Health Canada, the Public Health Agency of Canada, and the Canadian Institutes of Health Research began, through the Pathways to Health Equity for Aboriginal Peoples Initiative and Population Health Intervention Research to build evidence on risk factors and prevention of chronic diseases, including diabetes.

Addressing diabetes in Aboriginal communities

5.71 Health Canada, in collaboration with partners, should develop performance measures and use them along with surveillance information to assess and advance the diabetes activities funded under the Aboriginal Diabetes Initiative (ADI). (5.64–5.70)

The Department’s response. Agreed. Health Canada currently has performance measures built into community reporting mechanisms that form part of contribution agreement accountabilities.

Health Canada, in collaboration with First Nations, Inuit, and other partners, will

  • by August 2013, enhance these performance measures and use them to assess the impact of the ADI, including incorporating them into the Healthy Living Evaluation, which will be reported on in 2014;
  • by September 2013, use these enhanced performance measures along with the First Nations and Inuit Health Branch national surveillance strategy (see recommendation in paragraph 5.41) to assess and advance the diabetes activities funded under the ADI; and
  • provide increased support to regions to use data for health status reporting, as is currently done in Alberta and the Atlantic regions.

 


Definitions:

Prevention and control—Refers to activities such as taking action on common risk factors, developing knowledge and tools, and providing public information activities to reduce or delay the impact of disease and its complications. It does not include the provision of health care. (Return)

Health portfolio—Under the Minister of Health, this portfolio comprises Health Canada, the Public Health Agency of Canada, the Canadian Institutes of Health Research, the Hazardous Materials Information Review Commission, and the Patented Medicine Prices Review Board. Included in the scope of this audit are Health Canada, the Public Health Agency of Canada, and the Canadian Institutes of Health Research. (Return)

Surveillance—According to the Public Health Agency of Canada, the process of systematic collection, orderly consolidation, and evaluation of pertinent data with prompt dissemination of the results to those who need to know, particularly those who are in a position to take action. (Return)

Indicator—A single measure, most often expressed in quantitative terms, that represents a key aspect of health status, such as how many people suffer from diabetes and its complications. Indicators rely on consistency in data collection and are used to measure progress against benchmarks. (Return)

 

PDF Versions

To access the Portable Document Format (PDF) version you must have a PDF reader installed. If you do not already have such a reader, there are numerous PDF readers available for free download or for purchase on the Internet: