'Side conversations' root of First Nations health tragedy

Amid chronic failure of health care systems serving First Nations, governments are now referring to First Nation health systems as “broken.”

Current system has declining health outcomes despite billions spent

When Prime Minister Justin Trudeau visited La Loche, Sask., in January 2016, the community's acting mayor asked both Trudeau and Saskatchewan Premier Brad Wall to commit to a 10-year community development fund for La Loche. (Jonathan Hayward/The Canadian Press)

Amid chronic failure of health-care systems serving First Nations, senior bureaucrats are now referring to them as "broken."

This is a national tragedy — many First Nations lack access to even the most basic health services.

Billions are allocated annually for Indigenous health, with this federal budget adding $800 million over the next five years. Where does this money go? Why does it not have greater impact? Is the system really broken or is there another explanation?

Comparing the federal processes that distribute funding to medicare and First Nations health systems can provide perspective in finding these answers.

For medicare, federal funding is distributed directly through transfer agreements. Provincewide conversations result in funding distributed across health regions. Health regions distribute funding to hospitals, clinics and front-line workers. Each level has flexibility in how it spends its funds to achieve health priorities.

Conversely, we have become more efficient at responding to crises, such as the tragic shooting deaths in La Loche, Sask., but we have not fixed the structural problems of the First Nations health systems— which includes harmful side conversations.

Why side conversations are not effective 

In the Indigenous Health Alliance — a process that supports First Nations communities in fully exercising their inherent and Treaty Rights to health by returning accountability to, resource allocation towards and responsibility for implementation back to individual First Nations — the term "side-conversations" is used to describe the current system of Health Canada decision-making. 

Side-conversations exclude core stakeholders in decision-making processes to establish priorities, solutions and spending that is "side-conversation-centred" versus community and patient-centred.  

When priorities of government, researchers and consultants replace community priorities, First Nations become dependent on these groups to implement solutions. When First Nations push for our own priorities with workable solutions we have great difficulty getting them properly resourced, if ever.

Side-conversations are both ineffective and expensive.

Medicare recognized this almost a decade ago, investing hundreds of millions to transform health systems across Canada to create community and patient-centred systems.

Notwithstanding the goodwill of federal politicians, health care systems serving First Nations will continue to produce these unwanted outcomes because new resources maintain the current system design.

Final decisions on First Nations health funding are made by Health Canada, with input, behind closed doors. (CBC)

Federal funding does not go directly to First Nations

Canadians have a misconception that all federally-committed funding goes directly to First Nations.

Funding is instead sent to federal government departments, where it is retained until a spending strategy is decided.

There is input, but final decisions are made by Health Canada behind closed doors. These decisions are influenced by conversations with government staff, researchers and consultants, all pursuing part of the federally-committed funding. Part of this funding eventually flows to programs packaged and delivered to First Nations to administer.

For the funding that does make it to First Nations, obedience to program design is strict and enforced through contract. To obtain funding for any health service, First Nations must first sign contribution agreements and agree to government priorities set out in the packaged program, which often conflict with actual community priorities. The agreements have minimal flexibility and strongly penalize any deviation.

No contribution agreement means no Health Canada health care.

Decisions are made unilaterally by government at nearly every level of First Nations health care.  While there is a recent emphasis on community engagement, it is clearly communicated that consultation tables are advisory.

Spending and program design remains at the federal department's discretion.

This is the rule, not the exception.

2 systems, different outcomes

Medicare funding flows from province to front-line, with multiple levels of autonomy and flexibility. The trend is better value and better health outcomes. 

For First Nations, autonomy and flexibility are systemically minimized.  Decision-making authority is consolidated from patients and communities to bureaucracies and governmental departments; a pattern that permeates federal and provincial health and social systems.

The trend is worsening value and widening health disparities.

First Nations are left with the blame for health and social system failure.

Justin Trudeau arrives in La Loche, Sask., after a deadly school shooting. (Erin Collins/CBC)

In La Loche, Saskatchewan, hundreds of millions have been targeted to its population of 3,000. Millions of dollars have been directed to educational institutions and non-profits to address La Loche health and social crises this year alone since a tragic shooting left four people dead.

In Manitoba, federally transferred funding for child and family welfare isn't just ineffective, it's not even spent for its intended purpose; $32 million this year was put into general revenue instead of benefiting Indigenous children in provincial care. 

In northern Ontario, $222 million in 2016 First Nations targeted health funding has resulted in continued gaps in health care access; generally, First Nation communities saw little to none of this funding.  

Barrier to change 

The greatest barrier to change is government acknowledging its bureaucracy is designed to promote side-conversations and minimize the role of community-centred priorities and solutions. The federal government has no strategy to transform the health system to produce something different.

First Nations health systems are not broken; they function exactly how they were designed to work. We need to return to community-led priorities and solutions, as First Nations Indigenous organizations have argued in a step-by-step proposal (LINK) to the federal government for Indigenous health systems transformation.

The status quo is no longer an option for First Nations and we cannot wait for a bureaucracy that doesn't want to transform.

First Nations will continue to move forward with or without government. Not because transformation is easy, but because transformation must happen.

About the Author

Dr. Alika Lafontaine

Team lead, Indigenous Health Alliance

Dr. Alika Lafontaine, an an Oji-Cree anesthesiologist in northern Alberta, was born and raised in Southern Saskatchewan/Treaty 4 territory. As a team leader within the Indigenous Health Alliance, he competed in and won the 2016 Great Canadian Healthcare Debate, a competition voted on by more than 700 health leaders from across Canada. Lafontaine currently sits on the council of the Royal College of Physicians and Surgeons of Canada as well as the board of HealthCareCAN and is immediate past-president of the Indigenous Physicians Association of Canada. In April, he was awarded with the Emerging Indigenous Leaders Award from the Public Policy Forum, presented by the Prime Minister of Canada.