Financing a First Nations and Inuit Integrated Health System - A Discussion

The Scope of Integrated Health Funding

The direction seen from successful indigenous approaches to health systems is to an integration of both health and social service delivery. Even in a resource constrained environment as First Nations health care, duplication of services can occur. Currently, administration of programs are stove-piped, each incurring separate costs. In one First Nations community, prior to the integration of health and social services, nineteen directors existed, representing each of the different health and social programs funded in the community. As well as cost inefficiencies, quality of care may be stymied by a lack of coordination at the client level. Particularly in the counseling areas, different health providers may be following in each other's footsteps. From a patient's perspective, continuity of care may not be present, either horizontally between different primary care access points on a health-social continuum or vertically, as a patient progresses from primary to more specialized care.

Health Canada and the Department of Indian Affairs and Northern Development (DIAND) have each made progress in simplifying the funding process and instituting multi-year funding agreements, however in both cases, the single transfer of funds does not include all programs from the department, and the devolution of funds is primarily administrative. In a broad determinants of health approach, the synergy possible between the programs funded by these two federal departments is obvious, and in fact, many First Nations are currently coordinating these programs and funds as best they can within the limitations imposed by each department. With respect to the federal funds, a starting point for an integrated health funding arrangement would include all health funds from the Medical Services Branch (MSB) and the health-related funds from DIAND.

In the description of health and health related funds which follows, the province of Ontario has been used to illustrate the type and distribution of resources which could be included in an integrated system. Ontario provides an example of a provincial government which has on reserve health expenditure data available and which offers additional health programs directed to Aboriginal people, including First Nations communities.

Three different financial scenarios are presented: the province of Ontario as a whole, and two health authorities: a single community ("A") and a tribal council ("B") which represents several communities. Both of these health authorities have undergone Health Transfer. Figure 4 below shows the distribution of population, and a DIAND geographic class descriptor for each of these groupings.

Population source: DIAND (1998). Indian Register Population by Sex and Residence 1997.
Geographic descriptor source: DIAND (1996): First Nation Community Profiles: Ontario Region

Community size (on reserve) and geographic proximity to urban centres are two main factors in resource allocation for both MSB and DIAND. In terms of total status population obtained from the DIAND Indian Register, Community A and Tribal Council B are basically similar as both have approximately a 8800 membership. It is in the on reserve population, however, that these two communities provide distinct examples. Community A has over 80% of its population on-reserve, whereas Tribal Council B has a more typical on and off reserve spread, with slightly less people living in the community (43%) than outside its territory.

MSB provides community health services or resources to a community's entire population, and does not distinguish between status residents and other residents. The Community Workload Increase System (CWIS) provides a count of all community residents, and therefore its on-reserve population is generally slightly higher than the Indian Register count. Tribal Council B's CWIS population in 1997 was 4143 (10% higher); however Community A's CWIS population was
slightly lower than the Indian Register at 7134 (3% lower).

The province of Ontario provides yet another on reserve population count, this time for purposes of the Ontario Health Insurance Plan (OHIP) eligibility, which provides the lowest counts of the three sources of population: DIAND, MSB, Ontario (see Figure 5 for a comparison of all three populations).

source: DIAND (1998). Indian Register Population by Sex and Residence 1997;
MSB Ontario Region, and Aboriginal Health Office, Ministry of Health, Ontario.

For purposes of uniformity and consistency in the analysis which follows, the DIAND population count has been used in all subsequent per capita calculations.

These communities also present different scenarios for proximity to urban settings (see Figure 4). Using the DIAND classification, Community A is classed as urban, whereas Tribal Council B has a mixture of rural and urban designated communities.