Good things to know
if we want to close the gap
in First Nations health in BC
Josée Lavoie PhD,
School of Health Sciences
UNBC
The Transformative Change Accord
The First Nations Health Plan
Closing the gap means investments in:
1.
Mental health programs to address substance abuse and youth
suicide;
2.
Integrating the ActNow strategy with First Nations health programs;
3.
Pilot programs to improve the integration of acute care and community
health services for First Nations;
4.
Increasing the number of trained First Nation health care professionals;
5.
Increasing Health Authorities’ involvement in service delivery;
6.
Increasing Aboriginal participation in planning and decision-making;
7.
Improved cross-jurisdictional coordination through Health Partners
Groups (FNs, BC Health, FNIHB, academics and professionals, does
not include INAC); and
8.
Telehealth deployment.
Outline
1. Overview of the Policy Synthesis Project: the policy
and legislative framework
2. Overview of the First Nations health care system as it
exists on reserve, including its strengths and
challenges
3. Findings from the “Where to Invest Project”
4. Areas of focus
The BC health care system?
The First Nations Health Care System
The 2007 Tripartite First Nations
Health Plan, which operationalizes
the Tripartite agreement in regards
to health services, focuses
exclusively on “First Nations and
their mandated health
organizations.”
Figure 1 Percentage of Aboriginal peoples living on-reserve, in
rural areas and urban centres, in British Columbia
26.0%
on-reserve
59.7%
urban
14.3%
rural
Two funders, many health care systems
What glues these systems together? Legislation, policy, goodwill
Federal policies
The 1979 Indian Health Policy
the goal of Federal Indian Health Policy is to achieve an increasing level
of health in Indian communities, generated and maintained by the Indian
communities themselves.
The Public Health Agency of Canada 2007 to 2012 Strategic Plan
increase its capacity in Aboriginal health; and
develop a strong over-arching strategic Aboriginal public health policy,
based on collaborative relationships with national and regional Aboriginal
organizations and other federal departments.
Lavoie JG, Gervais L, Toner J, Bergeron O, Thomas G. Aboriginal Health Policies in Canada: The Policy
Synthesis Project. 2009. Prince George, BC, National Collaborating Centre for Aboriginal Health.
The provinces and territories
1. Provincial/territorial Aboriginal-specific health provisions
embedded in legislation
•
Provisions that focus on jurisdiction: AB, (Métis), SK, ON, NB
(Reserves)
•
Provisions related to information and consultations: MB
•
Provisions related to Self-Government Agreements: QC and
NFLD&LAB
2. Aboriginal-specific policies
•
NWT: Métis Health Policy – NIHB
•
BC: Transformative Change Accord – First Nations Health Plan
•
NS: Providing Health Care, Achieving Health – Mi’kmaq
•
AB, SK, MB, ON, NB and PEI: Use of tobacco for ceremonial
purposes
Lavoie JG, Gervais L, Toner J, Bergeron O, Thomas G. Aboriginal Health Policies in Canada: The Policy
Synthesis Project. 2009. Prince George, BC, National Collaborating Centre for Aboriginal Health.
What we know about
the BC on-reserve
health care systems
Type of Facility
■ Nursing Station (N=9):
Treatment, screening and prevention
● Health Centre (N=23):
Emergency, screening and primary &
secondary prevention
▲Health Station (N=72):
Screening and primary prevention less
than 5 days/week
∆ Health Office (N=2):
Primary prevention services only, less
than 5 days/week
What we know about
the BC on-reserve
health care systems
Models of Community Control
•Transfer (blue on map)
•Integrated (pink on map)
•NTNI (non-transferred, nonintegrated, green on map)
How robust is this system?
Table 3.5, MSB/FNIHB Annual Expenditures less NIHB in millions of dollars per Regions with percentage
increase, 1992 to 2002 (FNIHB unpublished data, 2004)
Fiscal
Year
NTH
ATL
QC
ON
MAN
SK
AB
BC
SEC
1992-93
13.871 23.169 64.443 48.493 32.778 32.237 34.614
1993-94
15.409 27.027 73.235 50.584 39.005 37.751 39.066 17.773 28.057 327.907 13.7%
1994-95
19.53
35.499 92.575 63.294 58.028 43.336 45.636 18.356 33.774 410.028 20.0%
1995-96
13.704
4.852
27.338
9.808
25.225 15.011 40.442 219.937 -86.4%
1996-97
23.136 36.657 98.677 28.049 56.524
22.02
60.536 29.584 39.616 394.799 44.3%
1997-98
24.816 39.361 103.354 77.722 59.722 60.305 63.426
56.237
27.32
9.705
HQ
%
Total increase
23.626 282.936
6.015
54.535 489.256 19.3%
42.177 109.052 82.349 63.328 62.859 71.968
5.462
76.111 540.006 9.4%
1999-2000 30.861 49.375 115.21 92.963 71.166 69.755 81.589
3.701
71.544 586.164 7.9%
1998-99
26.7
2000-01
37.661 55.757 124.679 104.062 76.62
73.817 82.832 54.398 68.983 678.809 13.6%
2001-02
46.873 58.811 132.008 107.202 85.811 81.018 91.104 62.105 93.876 758.808 10.5%
Lavoie JG, Forget E, O'Neil JD. Why equity in financing First Nation onreserve health services matters: Findings from the 2005 National
Evaluation of the Health Transfer Policy. Healthcare policy 2007; 2: 79-98.
How robust is this system?
MSB/FNIHB Expenditures less NIHB, 1992 to 2002
140
120
100
ATL
Millions of dollars
QC
80
ON
MAN
SK
AB
60
BC
NTH
HQ
40
20
0
Lavoie JG, O'Neil J, Sanderson L, Elias B, Mignone J, Bartlett J, Forget E, Burton R,
Schmeichel C, MacNeil D. The Evaluation of the First Nations and Inuit Health Transfer
Policy. 2005. Winnipeg, Manitoba First Nations Centre for Aboriginal Health Research.
Is it working?
British Columbia Provincial Health Officer. Pathways to Health and Healing - 2nd Report on the Health and
Well-being of Aboriginal People in British Columbia. Provincial Health Officer's Annual Report 2007.
2009. Victoria, BC, Ministry of Healthy Living and Sport.
But we know that we have work to do
British Columbia Provincial Health Officer. Pathways to Health and Healing - 2nd Report on the Health and
Well-being of Aboriginal People in British Columbia. Provincial Health Officer's Annual Report 2007. 2009.
Victoria, BC, Ministry of Healthy Living and Sport.
The “Where to invest project” (Manitoba
First Nations living on-reserve)
*Green et al. Diabetes Care 2003
The “Where to invest project”
Federal jurisdiction
Community control:
•Transferred
•Integrated
•NTNI
•Provincial/RHA
facilities
Local Access:
•Nursing Station
•Health Centre
•Health Office
•No facility
Sample: defined by postal code, no FN identifier
(5% “error” but same access issues). N = 64,933 in
1984/85, 71,510 in 2004/05.
GEE modeling
Provincial jurisdiction
Hospitalization for conditions
that could be treated in a
primary health care setting
The “Where to invest project”
•Communities with local access to a broader complement
of primary health care services (Nursing Station) show
lower rates of avoidable hospitalization (significantly
different from each other at the 0.05 level).
•The length of stay in hospital is also lower for residents of
community with better access to primary health care
(Nursing Stations/Health Centres vs Health Office, p <
0.0001).
Lavoie JG, Forget E, Prakash T, Dahl M, Martens P, O'Neil JD. Have investments in on-reserve
health services and initiatives promoting community control improved First Nations' health in
Manitoba? Social Science and Medicine, forthcoming (June 2010).
The “Where to invest project”
•After signing a transfer agreement (blue on the map), the
rates of avoidable hospitalization decrease with each
following year (p=0.05).
•In contrast, the slope of the rates of avoidable
hospitalization do not change as the number of years
post signing an integrated agreement (pink on the map)
increases.
•This cannot be attributed to transferred communities
being healthier to begin with (Chandler & Lalonde, 1998).
Lavoie JG, Forget E, Prakash T, Dahl M, Martens P, O'Neil JD. Have investments in onreserve health services and initiatives promoting community control improved First
Nations' health in Manitoba? Social Science and Medicine, forthcoming (June 2010).
The “Where to invest project”
8.0
Rates of avoidable
hospitalization over time
6.0
4.0
2.0
0.0
All FN
All Rural MB
All MB
Rates of hospitalisation
Age/sex adjusted Rate
Premature Mortality Rate, First
Nation sample and Manitoba
80.0
60.0
40.0
20.0
0.0
Transferred
All Rural MB
All MB
Lavoie JG, Forget E, Prakash T, Dahl M, Martens P, O'Neil JD. Have investments in on-reserve
health services and initiatives promoting community control improved First Nations' health in
Manitoba? Social Science and Medicine, forthcoming (June 2010).
Good things to know if we want to close the gap in
First Nations health?
•
Nationally, there is a patchwork of policies and provisions embedded
in legislation
•
The Transformative Change Accord and associated BC Health Plan are
important innovations
•
Gaps remain.
•
Findings from the Manitoba Where to invest project show that primary
health care investments on reserve and community control have had a
positive impact on outcomes.
•
We know that the sustainability of the on-reserve health care system is
questionnable, and that this is not being addressed.
•
We know that an erosion of the primary health care system (federal
jurisdiction) is likely to result in increased rate of avoidable
hospitalization (provincial jurisdiction).
Good things we need to know if we want to close the
gap in First Nations health?
•
We need to know more about the BC context.
•
We need to know whether the findings of the “Where to invest
project” apply in BC.
•
We need to address the sustainability of the on-reserve health care
system.
•
We need health services research that can help disentangle issues
of access to primary health care on- and off-reserve.
•
We need to build on strengths, and find out which communities are
successful at addressing hospitalizations for ACSC: and then we
need to ask them what they are doing, and learn from them.
•
We need to figure out how to best integrate the diverse health care
systems to create a seamless system for patients.
•
We need a federal policy that acknowledges its responsibilities,
and a government that is prepared to actually act on those
obligations.
 Wishing all of you a happy federal budget
day…