Patches of Equity: Policy and Financing of Indigenous Primary Health Care Providers in Canada, Australia and New Zealand

This thesis investigates how the governments of Canada, Australia and New Zealand balance the ideal of indigenous self-determination with other pressures, such as current trends in public administration and accountability, pressures on the health care system, issues of and sensitivities around minority rights, equity in health and cost-efficiency. It is based on four case studies conducted in Australia and New Zealand. The Canadian material is drawn from both the literature and a period of twelve years working in indigenous-controlled health services. All three governments have made some policy commitments to increased indigenous participation and self-determination, in the pursuit of health gains. The goal is a more responsive health care system. Self-determination is often mentioned. In Australia and New Zealand, the commitment extends to primary, secondary and tertiary care. Canada focuses exclusively on improving the responsiveness of on-reserve primary health care services. The contractual environment in which providers operate bears a highly nuanced resemblance to official policies. Two broad categories of contractual environments have emerged. Indigenous providers who operate in an environment where the funder is an indigenous-specific government authority (First Nations and Australia's new PHCAP program) have access to a relational contractual environment that is advantageous administratively, financially and in terms of comprehensiveness of services. Indigenous providers that secure funding from non-indigenous specific funders (New Zealand, and Australian Aboriginal Health Services) operate in a classic contractual environment where funding is accessed via a multiplicity of fragmented, often proposal-driven, contracts with high administrative costs. Classic contractual environments lead to a patchwork approach to achieving health gains. Indigenous aspirations for self-determination have been partially satisfied with increased opportunities for contracting in health. Although the link between increased indigenous participation and improved outcomes remains to be explored analytically, it is doubtful that classical contractual environments can yield the health gains expected

Contracting in First Nation contexts: pragmatic considerations

APHCRI Conversations was a regular program of presentations held at the Department of Health to facilitate exchange between APHCRI Network researchers and Department policymakers. Topics are developed jointly with the Department of Health and involve a range of speakers from APHCRI, including CRE invited experts, CRE Chief Investigators and stream project Chief Investigator

Policy and Practice Options for Equitable Access to Primary Healthcare for Indigenous Peoples in British Columbia and Norway

Over the past three decades, policy reforms have been geared towards improving quality of care, responsiveness, and equitable access to healthcare services for all social groups in general, and individuals living in marginalizing circumstances in particular. The purpose of this study was to document how primary healthcare services (PHC) services are provided in Norway and British Columbia to meet the needs of Indigenous peoples and use this knowledge to critically explore policy alternatives that inform the delivery of PHC for vulnerable populations. Findings show that in British Columbia, Indigenous-specific PHC services have been the preferred mechanism to ensure better care. This is not the case in Norway, where Sámi-centric services exist only in mental health and only in Finnmark

Public health politics in Nunavik health care : shared concepts, divergent meanings

In Nunavik, the question of self-determination in health care is becoming increasingly embedded in the community health discourse, which is used by both health planners and Inuit alike to negotiate diverging positions. While health planners envision northern health care as a subset of the Quebec system, Inuit perceive it as a vehicle to ends that transcend conventional health issues. This thesis will provide an overview of the development of Nunavik health services since the James Bay agreement, focusing on how the use of the community health discourse serves to promote, but also shapes and limits regional and community self-determination

Defined by 0.11%: Policies delimiting access to prescription drugs for First Nations people in British Columbia

The Non-Insured Health Benefits (NIHB) program is a federal program that funds prescription medication, as well as other primary healthcare benefits, for First Nations people registered under the Indian Act and for Inuit. NIHB policies have been developed within the Canadian political realities of ambiguity in interpretation of historical legal obligations, patterns of cost shifting onto provincial governments, and a move towards chronic disease management. This study critiques the ambiguities embedded in NIHB and provincial pharmaceutical benefit policies for First Nations people in British Columbia. British Columbia’s Fair PharmaCare and PharmaCare Plan C provincial prescription programs are compared to NIHB. We conducted a review of these policies and completed our understanding by interviewing three pharmacists to better understand decisions surrounding the dispensing process. Four themes surfaced from our analysis: discrepancy between policy and practice in terms of federal versus provincial responsibility; restrictive processes of access to coverage; a system dependent on pharmacists’ goodwill when NIHB denies a claim; and NIHB policies at times being at odds with pharmacists’ clinical judgment and business compensation. Our findings suggest the existence of an ethnically differentiated social contract that perpetuates rather than diminishes barriers to care for First Nations people

Regionalization as an Opportunity for Meaningful Indigenous Participation in Healthcare: Comparing Canada and New Zealand

In Canada and New Zealand, policies support Indigenous participation in the planning and delivery of community-based primary health services. However, these services represent only a fraction of the health services accessed by Indigenous peoples. In New Zealand, legislation enacted in 2000 introduced mechanisms to ensure that Māori have a voice in the decisions made by health boards. In Canada, neither policies nor legislation currently ensure that Aboriginal communities are represented in provincial health systems or regional health boards. The New Zealand experience shows that adding mechanisms of participation to legislation and policies creates opportunities for Māori and health boards to engage in discussions about how to best allocate resources to reduce disparities between Māori and non-Māori health outcomes. In Canada, this dialogue may not occur. Requiring that such mechanisms be created in all Canadian jurisdictions would establish meeting places for dialogue, and assist in closing policy and access gaps that remain