Financing a First Nations and Inuit Integrated Health System
- A Discussion
The Scope of Integrated Health Funding
Community Expenditures
Figure 8 provides a comparison of the total health and health-related
expenditures for Community A and Tribal Council B by source of
funds:
- Medical Services Branch (MSB)
Both health authorities have completed health transfer, and the
majority of the non-insured health benefits (NIHB) expenditures
are captured in these agreements. Non-transferred expenditures
in both communities include Aboriginal Head Start, Health Careers,
health liaison, consultation funds, Canada Prenatal Nutrition,
and the Green Plan (under Environmental Health and Surveillance).
In addition, Community A receives $86,365 for administration
of its NIHB Program which exists outside of the Health Transfer
agreement. The total expenditures for both communities are comparable
at $7.8 million in Community A and $8.3 million in Tribal Council
B, which at face value might be not surprising given the similar
populations of both bands. However as the following section illustrates,
Community A, because over 80% of its population live on reserve
compared to less than 50% for Tribal Council B, has a far smaller
per capita allocation.
Figure 9 provides a per capita comparison for both communities.
With respect to NIHB per capita costs which have been calculated
using the total population, Tribal Council B at $558.89 per person
is 6.2% higher than Community A, and most likely is attributed
to the increased costs seen in a rural population which has poorer
access to health providers and higher medical transportation
expenditures. The economies of scale achievable with a larger
community which is not spread out over seven separate reserves
are seen in the per capita calculation for the non-NIHB
program expenditures as Community A expenditures were less than
half of Tribal Council B's ($425.73 versus $907.75).
- Province of Ontario
Figures 8 and 9 provide community comparisons for the main program
areas funded by the province of Ontario, by gross expenditures
and per capita expenditures. These expenditures are described
below.
Aboriginal Healing and Wellness Strategy
The expenditures provided in Figures 8 and 9 encompass all operational
dollars under the Aboriginal Healing and Wellness Strategy (AHWS),
including one-time grants. Capital expenditures have been excluded.
Both communities have been funded for Community Health Access
Centres under the Aboriginal Healing and Wellness Strategy and
operate with $1 million in annual funding. (Note 51: Descriptions
of the services funded by the Aboriginal Healing and Wellness
Strategy was obtained from its 1996/97 Annual Report.) Tribal
Council B's Health Access Centre is a partnership with a neighbouring
Friendship Centre and provides services to both on and off reserve
Aboriginal people. It provides holistic treatment, health promotion
and prevention services at several community-based health stations
or at the homes of clients who have difficulty traveling. Community
A's Health Access Centre serves the community residents and those
members living off-reserve in neighbouring urban centres. It
employs a dentist, registered nurse, practical nurse, dietician/nutritionist,
medical records clerk, outreach worker and a program manager.
Physicians and specialists serve the community on a rotating
basis. To support this activity, lab services, physiotherapy,
occupational therapy and speech therapy are offered on a part-time
basis.
Apart from the Access Centre, Tribal Council B is funded by the
AHWS for community prevention and health promotion workers through
the Association of Iroquois and Allied Indians and the Union
of Ontario Indians. Community A receives funding from the AHWS
for its Expanded Shelter Project. The shelter facility contains
5 three bedroom units and is staffed by two outreach and child
care workers who provide counseling to the community.
Overall, the AHWS expenditures are similar for both communities
at approximately $1.4 million, however when calculated on a per
capita basis using the on reserve population, a difference is
apparent similarly to that seen with the MSB expenditures above.
Community A's per capita expenditures are roughly half ($184.10)
of that calculated for Tribal Council B ($377.51). This per capita
calculation may be inaccurate, given that both communities' Health
Access Centre serve off reserve residents, and in the case of
Tribal Council B, all Aboriginal people in the catchment area.
However, if the total member population in a per capita calculation
is used, a more comparable expenditure level of $152.70 for Community
A, and $162.64 for Tribal Council B is obtained.
Ontario Health Insurance Plan (OHIP) and Acute Separations
Figures 8 and 9 show a sizable difference between both communities
regarding physician and hospital expenditures, both in gross
and per capita illustrations. It might be expected that Tribal
Council B would have increased medical costs as ruralness in
Northern Ontario is generally associated with lower socio-economic
circumstances and this is often accompanied by poor health status.
The submitted expenditures show that Community A expended $56.83
per capita on OHIP and $69.68 per capita on acute care hospitalization,
with Tribal Council B posting a expenditures of $245.10 and $197.01
respectively.
Health Programs
A different spectrum of health programs (outside of the AHWS)
are funded for each community by the Ontario government. In Community
A, this funding is primarily for nursing services in its residential
care facility, with a lesser amount for emergency services (ambulance).
Tribal Council B receives funds for a pilot project "Best
Start" (prenatal and infant care to ensure children and
families and pregnant women have a nutritionally balanced lifestyle),
for the Northern Diabetes Network, and for community support
services to Elders (such as meals on wheels, day programs, respite
care, home help etc.). In addition, Tribal Council B homemaker
and nursing services are provided by MCSS under the 1965 Agreement,
with the majority of these expenditures reimbursed from the federal
government.
Overall, the province of Ontario's per capita calculations show
that Community A's expenditure at $362.12 is 33% of that seen
with Tribal Council B ($1,102.16). If the alternate per capita
calculation for AHWS funds are used (see above), Community A's
total provincial expenditure is $330.72 which is 37% of the Tribal
Council B's per capita expenditure of $887.29.
a. Community A's total physician costs,
including expenditures for residents residing in Quebec were
a $110.68 per capita. This additional amount includes payments
to Ontario physicians for services to persons covered under the
Quebec provincial insurance plan and the differential costs (between
the Ontario reimbursement rate and the lesser Quebec rate) which
were paid out of the NIHB Program.
- Department of Indian Affairs and Northern Development
(DIAND)
Most of the DIAND expenditures are paid directly to the Ministry
of Community and Social Services (MCSS), nursing homes or Political
Treaty Organizations (PTOs), and therefore no categorization
of expenditures by community is possible. For descriptive purposes
in Figure 8, a straight allocation based on population has been
provided, with the exception of Adult Home Care where community
breakdowns were available, the expenditures for the residential
care institution (adult and child care components) and an emergency
shelter in Community A, and a direct allocation for family violence
services in Tribal Council B. Because of this, the DIAND gross
and per capita expenditures provided in Figures 8 and 9 should
be viewed with caution, as hypothetical not actual. Expenditure
estimates to the two communities reviewed here which were received
from DIAND include the following:
- $1,008,400 - residential care - adult Community A
- $206,800 - emergency shelter Community A
- $179,799 - institutional care - child Community A
- $651,800 - adult home care Community A
- $296,100 - adult home care Tribal Council B
- $12,600 - family violence Tribal Council B
Community allocations based on population were calculated for
MCSS home care funding, MCSS and PTO child and family services,
adult institutional care (other than Community A) and PTO family
violence services, and were integrated in Figure 9 with the expenditure
estimates detailed above.
The allocation which is presented shows Community A as receiving
higher expenditures from DIAND than Tribal Council B. This is
likely a reality, due to the presence of its residential care
institution which is funded entirely by DIAND (with the exception
of some Ontario funded nursing services mentioned above), and
the funding of an emergency shelter.
Combined Expenditure Scenarios
Figures 10 and 11 look at the total resources available on a per
capita basis for two scenarios of an integrated funding model:
combining the health expenditures of MSB and the province of Ontario
or secondly combining all health and health-related expenditures
by the addition of DIAND. Regarding the first scenario, $1,314.04
per capita would be available for inclusion in an integrated health
funding model for Community A, and $2,568.80 for Tribal Council
B. On a gross expenditure basis, Community A's envelope would be
$10.4 million with $12.5 million available for Tribal Council B.
The increased expenditure base of Tribal Council B can be attributed
to its geographic location (a consideration in MSB formula based
allocations), the small community sizes, and the amalgamation of
several communities with health clinics and separate fixed costs
in each. Also the increased costs are likely related to demonstrated
health needs which will have (at least to a limited extent) driven
the scope of health services provided and which may explain the
large difference seen in OHIP and acute hospitalization expenditures.
The second scenario which incorporates DIAND resources has presented
hypothetical DIAND allocations as much of the health related resources
from DIAND is paid directly to MCSS (for 1965 Agreement services),
PTOs or nursing homes and is not available on a per community basis.
The presence of institutional facilities (adult care, child care
and emergency shelter) in Community A is resource intensive and
contributes $1.4 million in identifiable resources. In this scenario,
Community A would receive $15.6 million or $2,013 per capita and
Tribal Council B would receive $14.3 million or $3,081 per capita.
For both scenarios, administration costs which have not been itemized
in the above analysis would be an additional component to the community
envelopes. Costs which are not present in the expenditures provided
are those relating to the administration of the DIAND programs,
and the non-AHWS provincial programs. The role and size of the
funder departments in an integrated health funding system will
influence the amount of resources to be retained for administration
in each of these organizations.
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