Financing a First Nations and Inuit Integrated Health System
- A Discussion
Aboriginal/Indigenous Health Systems
A funding model that holistically incorporates health and health
related services is compatible with the Aboriginal view of health
and well-being. The Medicine Wheel, or Circle of Life provides
a framework for holistic healing which encompasses physical, mental,
emotional and spiritual domains. Only in the last twenty years,
has the mainstream health system adopted a similar perspective,
one which acknowledges that health and well-being stem from a variety
of factors and influences, classified as ' broad health determinants.'
These determinants include social and economic forces, psychological
influences, physical and genetic factors and cultural elements.
The importance of health determinants has been validated in numerous
studies which have shown the connection between health status and
a number of factors including income, position in society, employment,
lifestyle factors, and control over one's personal situation. As
well, international comparisons of per capita spending, life expectancy,
and morbidity rates have illustrated that countries which spend
high amounts of money on health expenditures do not have the best
health indicators (Note 18: OECD Secretariat. 1990. Health Care
Financing Review: Annual Supplement.Organization for Economic Cooperation
and Development: Paris.) (OECD Secretariat. 1990. Health Care Financing
Review: Annual Supplement. Organization for Economic Cooperation
and Development: Paris. ). Beyond a certain level, investments
in illness care services do not equate to the same magnitude in
improved health status, which suggest that other factors are important
in improving population health (Note 19: Robert Evans and Gregory
Stoddart. 1990. "Producing Health, Consuming Health Care" Social
Science and Medicine 31(12):1347.). Certainly the situation in
Aboriginal communities provides a real life example of the impact
of health determinants, such as poverty, nutrition, living conditions
and unemployment on individual and community health and well being.
Despite the importance of health determinants in individual and
population well-being, the Canadian health system has retained
a primarily clinical (and with respect to insured services, a medical)
focus. This is the system that First Nations communities have inherited.
It is particularly difficult in an environment where health and
social programs are in protected envelopes to design and implement
holistic solutions. Integrated health funding will provide the
first step to achieving a more responsive, and community oriented
health system. Ultimately, social service funding should be combined
with the health and health-related dollars, and a system set up
to seamlessly transfer individuals between housing, health, home
care and other services.
For Aboriginal people, holistic healing which interrelates physical,
mental, emotional and spiritual elements, will restore not only
wellness to individuals, but also renew their capacity to exercise
collective responsibility and build caring, inclusive communities
(Note 20: Aboriginal Healing Foundation. 1998. Backgrounder, Aboriginal
Healing Foundation:Ottawa.). The Royal Commission on Aboriginal
Peoples (RCAP), in its final report, identified several areas where
Aboriginal health and healing concepts are congruent with the health
determinants model:
- True health comes from the connectedness of human systems not
their separate dynamics. The four components of the healing circle
reinforce the results of research on health determinants. "Health
is the total effect of vitality in and balance between all life
support systems."
- Economic factors are particularly important in determining
the level of health of a population.
- Responsibility for health is both individual and collective.
Personal choices on lifestyle (smoking, diet, exercise etc.)
combined with an individual responsibility for well-being are
complementary to Aboriginal perspectives on collective responsibility
for community well-being as well as individual self-care.
- Aboriginal beliefs regarding good health are based on balance
and harmony within one's self and within the social and natural
environment. This is echoed in research that has proven causal
links between stress and ill health.
- A healthy and happy childhood is the foundation for life.
Many factors influencing health status throughout life are to
be found in childhood and before birth, such as poverty, accidents
and injury, and smoking and alcohol consumption during pregnancy.
(Note 21: RCAP. 1996. page 223.)
An integral component to restoring balance and well-being to communities
involves community empowerment as well as individual well-being.
The ultimate expression of an Aboriginal health system that embodies
both individual and community empowerment is self-government; however
a practical first step on this journey to assuming control over
a health system, would be a system of integrated funding.
Despite concerns expressed by many First Nations about Health
Transfer being merely an administrative devolution of services,
recent survey results indicate that more communities with transfer
feel their services are equitable to other Canadians, than do non
transferred communities. This has been seen the First Nations and
Inuit Regional Health Survey Project, which was conducted in 183
First Nations and 5 Labrador Inuit communities. A total of 9,870
adults were surveyed representing 199,782 First Nations and Inuit
adults in participating communities. In a general question about
comparability of health services to other Canadians, only two variables
were found to be factors influencing the responses: presence of
transfer and geographic isolation. The survey results demonstrated
that the percentage of Aboriginal people who thought that the quality
of their health services was equivalent to those of other Canadians
was significantly higher in the communities which underwent Health
Transfer: 35.3% from transferred communities versus 27.9% from
non-transferred communities (Note 22: National Steering Committee
of the First Nations and Inuit Longitudinal Health Survey.1998. Summary
of the National Reports. National Steering Committee: Ottawa.
page10-11.). (It is unlikely that the mere presence of transfer
unduly biased respondents into answering favorably, as for example,
the Manitoba portion of the survey revealed that 35% of First Nations
in that region were unsure if their health services had been transferred
to band control (Note 23: O'Neil, J., A. Leader, B. Elais, and
D. Sanderson. 1998. "Manitoba Regional Health Survey: A Preliminary
Report of Selected Results." Abstract published in National
Aboriginal Information and Conference Report. National Steering
Committee of the First Nations and Inuit Longitudinal Health Survey:
Ottawa.). ) With respect to geographic isolation, 62.2% of Aboriginal
people living in isolated communities did not believe they received
the same quality of health services as Canadians, compared to 56.4%
in non-isolated communities. (Note 24: National Steering Committee
of the First Nations and Inuit Longitudinal Health Survey.1998.
page 10-11. )
In a review and analysis of successful indigenous health programs
in Canada, United-States (US) and Australia, common strengths from
an operational perspective included:
- authority over education, health and social services
- ability to offer a wide range of social services and health,
including housing, emergency housing, food bank, training and
education
- comprehensive services
- incorporation of cultural and traditional components
- capacity built at the community level (for evaluation and
curriculum development)
- recognition and utilization of existing skills and resource
people in the health system
- close working relationship with other social services agencies
and local politicians
- support from the surrounding non-First Nations community due
to a strong profile by the First Nation
- bilateral negotiations with the province
- evaluation, as a built-in, health outcome oriented component
of programs. (Note 25: Sutherland, Cheryl. 1997. Indigenous Health
Systems: A review and analysis of successful programs in
Canada, US and Australia, designed and delivered by First Nations
and indigenous peoples. Part II: study examples. Assembly
of First Nations: Ottawa.)
In a financing model which ultimately included hospital and physician
budgets as well as community health and health related funding
from the federal government, First Nations would have the ability
to fundamentally reform the primary care system, not unlike what
is now being envisioned by provinces for their health systems (Note
26: In particular, Ontario is interested in developing integrated
health systems which are capitation based, and has recently announced
four pilot projects in this area. British Columbia, Alberta, and
Saskatchewan have joined with Ontario in researching the benefits
of capitation and integrated health systems, including the formula
for calculating capitation rates and governance authorities in
such a system.). Ultimately an integrated, functioning First Nations
health care system may need multiple entry points to increase accessibility
to health care, such as through community health representatives
(CHRs), traditional healers, and health professionals such as nurse
practitioners.
Nurse Practitioner Model - The Weeneebayko
Experience
A nurse practitioner model has been implemented in the Weeneebayko
Hospital in Moose Factory, Ontario, as part of the transfer of
the health system to First Nations. The restructuring efforts which
resulted in the Weeneebayko Health Ahtuskaywin Authority (WHA)
has included negotiations with both provincial and federal governments
due to the presence of the First Nations administered hospital
(previously called Moose Factory Hospital) in the region. Physician
services are provided through a cost-sharing agreement between
the province and the Medical Services Branch (MSB). MSB's portion
is included in a contribution agreement with the WHA, which in
turn reimburses Queen's university. Recently, as part of the health
authority redesign, this physician services contract was expanded
to include three nurse practitioners and one midwife position.
The nurse practitioner positions are being phased in with one in
place, one being currently hired, and the third expected in July,
1999. The hospital has had trouble recruiting the second nurse
practitioner, however, due to competition from inner city clinics
in Toronto which are also hiring nurse practitioners and the undesirability
of the northern locale for many health professionals.
The Weeneebayko experience in designing a First
Nations transferred health system is informative to a discussion
on a an integrated health funding model for a number of reasons.
To begin with, despite a sincere belief that things could "really
be done differently" in term of service design, it was realized
that there were good reasons for the way MSB delivered services
the way they did and therefore radical changes were not made to
service delivery. Nonetheless, the establishment of a single regional
health board, which has representation from each of the member
northern communities plus the southern communities which are relied
on for services, has been key to the success of the transfer. The
Board initiated a community consultation which has driven the system
planning process. (Note 27: Interview with Ms. Rachel Cull, Director
of Nursing, Weeneebayko Hospital, November5, 1998.)
The importance of accessibility to primary care
cannot be overstated in Aboriginal health systems. Aboriginal people
require multiple entry points into the system, such as CHRs, traditional
healers, nurses, nurse practitioners and physicians. Accessibility
is a perception as well as reality, for example, community members
may not feel comfortable approaching a health clinic to see a visiting
physician. Integrated health funding provides the flexibility to
provide enhanced accessibility in the health system, and in the
process also saves money. Numerous studies have established that
nurse practitioners are cost efficient. In non-Aboriginal settings,
they have been shown to reduce the use of ambulatory and emergency
room visits, decrease hospital utilization rate, reduce radiology
and lab costs without changing illness outcomes and increase the
use of non-drug therapy. (Note 28: Mitchell, Alba et al. undated.
Utilization of Nurse Practitioners in Ontario: Executive Summary.
School of Nursing, McMaster University: Hamilton. )
The Weeneebayko health system has successfully
integrated its first nurse practitioner into its primary care services.
She is based in the family medicine clinic at the hospital, and
conducts urgency clinics and participates in the first call rotation
at the emergency department. She deals with patients within her
scope of practice, and relieves physicians of minor complaints
which form a major part of a family clinic. The nurse practitioner
credentials allows her to work independently, and to refer clients
to physicians as appropriate. In the regular clinic, she handles
follow-ups and repeat clients as well as those who have consented
to see her. The number of repeat clients has indicated to the hospital
management that this type of health professional has been accepted
by the community. At the present time, the nurse practitioner position
is limited to working in the hospital clinics. As the second and
third nurse practitioners are added, this service will be considered
for the nursing stations in the surrounding communities. This new
role will be clearly defined in the nursing stations, to prevent
nurse practitioners from doing work of the registered nurses who
work full-time in these stations. (Note 29: Interview with Ms.
Rachel Cull, Director of Nursing, Weeneebayko Hospital, November5,
1998.)
An important factor to the successful integration
of non-physicians into primary care roles usually provided by physicians
will be the ability for individuals to choose who they see (at
least initially), so that they do not feel that they have been
handed off to a cheaper, inferior system. Through client education
and confidence in this new provider, a successful transition to
this new service model can occur.
Health and Social Integration - The
Nuu-chah-nulth Experience
A common theme among all the health systems reviewed for this paper,
is need for a holistic health focus, one that allows coordination
among services, links community resources such as the National
Native Alcohol and Drug Abuse Program (NNADAP) workers and mental
health workers with medical services, and deals with duplication
of services. (Note 30: For example, there may be cross over between
family and child services, and mental health workers both who may
go into the home to provide counseling to a family. In some cases,
even nurses will become involved in counseling.) One such approach
is the Nuu-chah-nulth Community and Human Services organization
on Vancouver Island which serves 14 communities north of Port Alberni,
British Columbia. Although the communities wanted a health system
that integrated health and social services, they initially started
out with Health Transfer in 1988. In 1992, the services were amalgamated
into one board, offering child welfare, health, education and social
services. By centralizing the services into an office of 30 staff
with up to 60 additional workers at the community level, all 14
communities have access to a level of programming which would not
have been possible individually. Since 1993, MSB funds flow through
the Department of Indian Affairs and Northern Development (DIAND)
under a single Alternate Funding Agreement; however the communities
are working towards block funding of all government funds, which
would remove program funding with its onerous reporting requirements.
A strength of this community's approach has been
the integration of education into the health and social mix. Training
is a priority at all levels. A life skills course in the community
includes those employed persons, and is directed to enhancing individuals'
working skills. Native education workers participate in the mainstream
education system, and act as liaisons, counsellors and teachers'
aids to the First Nations children attending the mainstream schools.
Control and influence on curriculum is achieved to some extent
through the funding arrangement which flows resources through the
tribal council to the education system. Post-secondary education
is also a priority with the Nuu-chah-nulth Board. It has developed
cultural-based units on First Nations studies (including art, social
sciences and science) to address the fact that many First Nations
high school graduates lack science background for post-secondary
training. (Note 31: Sutherland, Cheryl. 1997. page 20-22.)
Sioux Lookout Zone - Vision for the
Future
As part of health needs assessment for the Sioux Lookout First
Nations Health Authority, key informants and health workers were
asked what kind of health care system they would like to see developed
in their Zone and what kind of changes were needed. Most respondents
had difficulty in articulating a vision, and spoke in terms of
needing more of the existing services, better coordination between
different agencies, more consultation between First Nation government
and health professionals, and better understanding and cooperation
among health professionals. The responses support the integrated
health funding approach described herein, including:
- health care is part of self-determination
- need to redirect resources to health promotion and disease
prevention
- recognition of the importance of spiritual and cultural dimensions
of health.(Note 32: Young, T.K. 1995. Sioux Lookout First Nations
Health Authority Participatory Research Project. Final Report
I - Health Needs Assessment (revised). Northern Health Research
Unit, University of Manitoba: Winnipeg.)
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