Financing a First Nations and Inuit Integrated Health System
- A Discussion
First Nations and Inuit Integrated Health Funding
Why is it needed?
This paper's overview has introduced some of the main catalysts
to the establishment of an integrated health funding model. The
justification to a further evolution of financing arrangements
is multifaceted and as described in this section, is based on Aboriginal
desires for enhanced control over health services, the need for
flexibility in designing health programs, the current policy directions
of the federal government and the limitations imposed by the current
system to proactively meet the fiscal realities of capped resources
and a growing Aboriginal population.
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Limitations of Health Transfer
As already highlighted, one of the main impetuses
for reform to the financing mechanism in First Nations and Inuit
health care relates to a desire by First Nations and Inuit to obtain
more control over their health system. Health Transfer is the current
mechanism to provide increased community control, but it has been
subject to various criticisms, for example, some First Nations
feel that it will impinge on their rights guaranteed under treaties
and the fiduciary responsibility of the federal government. First
Nations are also concerned about future roles and responsibilities
of Health Canada. The Auditor General in his 1997 review of the
Medical Services Branch (MSB) concluded that the framework for
transfer was basically sound, although accountability mechanisms
and evaluation procedures were in need of development. He highlighted
the concern of some First Nations that the government may be pursuing
a 'dump and run' strategy, and that communities would not
be prepared to adequately design and manage health programs when
MSB leaves the service delivery business (Note 5: Auditor General.
1997. Report of the Auditor General of Canada to the House
of Commons. Chapter 13: Health Canada - First Nations Health. Minister
of Public Works and Government Services Canada: Ottawa.). In the
end, this scenario could be judged, sometimes unfairly, as mismanagement
by bands or communities.
Communities which have transferred have more operational concerns,
and transfer is seen as an intermediary, rather than final step
to full self-determination in health care. The existing transfer
arrangements have been described as mainly an administrative devolution
of services, as communities report that they are restricted in
the type and scope of health programs which may be implemented
under health transfer. Communities despite the stated health transfer
objective "to enable Indian communities to design health programs,
establish services and allocate funds according to community health
priorities" find that their final approved community plans
resemble closely existing MSB programs and services. This may be
due, in part, because the transfer budget is only one part of the
communities' primary care resources, and the community cannot access
for transfer, either physician budgets (a responsibility of the
provincial governments) or other primary care resources, such as
dental, vision and chiropractor services (which remain outside
of transfer in the MSB envelope). Primary care funds eligible for
transfer, particularly in small communities with only visiting
nursing services and a community health representative, present
a limited, partial resource pool for system redesign.
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Focus of the Western Health System
The Canadian health system is focused on curative
services. As well, the mainstream health system's emphasis is on
physical and mental domains over the spiritual and cultural components
of well being. Compounding this is a lack of integration of social
and health services at federal, and First Nations/Inuit levels,
and also in most provinces. Thus, there is no single, concerted
approach to improving health through addressing biomedical and
social needs of a community. Integration of funding will provide
a tool for First Nations and Inuit communities to develop a greater
coordination of health and health-related services, and it will
lay the foundation for future integration of social services as
communities progress in their self-government aspirations.
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Lack of Culturally Sensitive or Traditional
Programming
Culturally based health programming, which Aboriginal
people have clearly stated is crucial to improving community and
individual well being, is still rare, and therefore a holistic
approach to healing does not commonly exist,. This paper does not
advocate any particular method of healing whether it be western-based
or traditional, rather its purpose is to identify potential areas
for health system improvement which may be facilitated by the devolution
of financing to community control. The section "Aboriginal/Indigenous
Health Systems" addresses in more detail Aboriginal views of health
service delivery.
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