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.
Figure 4
Population (DIAND, 1997/98) and Geographic Class Ontario, Community
A and Tribal Council B
Population
(DIAND, 1997/98) and Geographic Class |
on reserve
pop (DIAND) |
off reserve
pop (DIAND) |
total pop
(DIAND) |
geographic
class |
Province of Ontario |
69,825 |
72,583 |
142,408 |
|
Community A |
7333 |
1507 |
8841 |
urban |
Tribal Council
B |
3767 |
4977 |
8744 |
urban/rural |
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).
Figure 5
On-Reserve Population Counts
|
DIAND |
CWIS |
Ontario |
Community A |
7,333 |
7,134 |
7,200 |
Tribal Council B |
3,767 |
4,143 |
3,666 |
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.
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