Introduction to the Special Issue: Indigenous Self-determination in Health Systems Reform

Chelsea Gabel
McMaster University, Hamilton, Ontario, Canada

Josée Lavoie
University of Manitoba, Winnipeg, Manitoba, Canada

Special Issue: Indigenous Self-determination in Health System Reforms

Guest Editors

Chelsea Gabel
McMaster University

Josée Lavoie
University of Manitoba

Across Canada, First Nations, Inuit and Métis peoples and communities live in rural, remote, Northern and reserve places, as well as urban places, and experience health inequities when compared with non-Indigenous peoples. These inequities are founded by pervasive colonial ideologies, policies, systems, and practices, many of which persist today resulting in multiple disparities in health as well as social, political, and economic areas (Adelson 2005; Allan and Smylie 2015).

In Canada, the federal government’s role in the provision of health services is primarily through the limited public health and prevention services offered by the First Nations and Inuit Health Branch (FNIHB), now Indigenous Services Canada (ISC). Services are offered to status (registered) First Nations living on-reserve and to Inuit living in their traditional territories. They provide non-insured health benefits (NIHB) such as prescription drugs, dental, and vision coverage to all status/registered First Nations and Inuit, regardless of where they live; however, non-insured health benefits are not offered to Métis or non-status First Nations. As a result of historical legislative vagueness, and the multiplicity of authorities that has resulted, the First Nations, Inuit and Métis legislation and health policy framework is very complex, which itself results in a great deal of diversity in health service provision across provinces and territories. The framework fails to adequately address the health care needs of the Métis or First Nations and Inuit people who are either not registered or not living on reserve or in their traditional territory (Lavoie and Gervais 2012).

Canada’s Health Transfer Policy (HTP), first introduced in 1989, promotes community uptake of services formerly funded by FNIHB, now ISC, for First Nations living on reserve (Gabel and Powell 2023). It followed a long series of ‘consultations’ between First Nations and the Canadian government on how best to address the inequalities that existed between First Nations people and the rest of the general population (Reading and Wien 2009; Gabel and Powell 2023). The policy allowed the Canadian government to transfer their health care funds to First Nations communities so that they can facilitate their own health resources based on community needs (Adelson 2005; Gabel, DeMaio, and Powell 2017). Today, many First Nations who reside on reserve design and implement their own community health programs and employ the majority of their health services staff. Benefits of the health transfer policy have included increased community awareness of health issues, more culturally sensitive health care delivery, improved employment opportunities for community members, a sense of empowerment and self- determination, and an improvement in the community’s health status and overall well-being (Lavoie et al. 2005).

However, the current state of health care provision for First Nations, Inuit and Métis peoples in Canada is still a patchwork of policy and programs with significant overlaps and gaps whereby different governments continue to debate who has financial responsibility (i.e., Jordan’s Principle¹)(Lavoie 2013). In recent decades, new challenges have emerged around how innovations since the 1980s are best scaled, as the magnitude of needed transformation is immense (Gabel and Powell 2020), and broader learning from pockets of innovation encumbered by geographic, structural, social, and cultural diversity across Indigenous contexts (Lavoie 2013; Henderson et al. 2018).

Despite destructive colonial policies and practices, such as the Indian Act of 1876, the implementation of the reserve system and theft of Indigenous lands, and the residential school system, Indigenous communities and cultures resist and persist today. It is evident that from the outset of this special issue, the diversity, resiliency, and strength of Indigenous Peoples must be highlighted. Today in Canada and around the globe, Indigenous communities are reclaiming lands, languages, identities, histories, cultures, artifacts, and stories, which were all but lost over the past hundreds of years since contact and are now being renewed and revived through processes of decolonization, reconciliation, self-determination, and sovereignty.

The purpose of this special issue is to highlight the experiences of diverse Indigenous communities and nations where health system transformation is actively taking place and creating new opportunities and challenges within communities. It offers a comprehensive overview of the impacts and outcomes of health policy and system change among historically marginalized Indigenous communities in various geographic locations, which have often been overlooked in political discourse for various perceived reasons. Additionally, this special issue contributes to the ongoing examination of the pervasive influence of settler colonial values and ideologies within structural determinants of health, such as policy and health systems. It aims to uncover and identify the processes in place within government structures that serve to substantiate settler colonial goals, and oppose the visibility and voice of marginalized, racialized, and other historically ‘problematic’ peoples. The articles serve to illustrate the complex structures and dynamics between Indigenous and non-Indigenous communities and the state. Moreover, they strive to adopt community and strengths-based research approaches, where communities confront and resist systemic challenges and inequities with established support systems, robust political advocacy, and innovative, community-driven solutions.

The first article in this series, “Comparing federal indigenous health policy reform in Canada and the United States: the shift to Indigenous self-determination in health care” by Denise Webb, Angela Mashford-Pringle, Sara Allin and Dane Mauer-Vakil (2022) compares the historical shifts in Indigenous health policy between Canada and the United States, focusing on the transition from assimilationist approaches to policies supporting Indigenous self-determination. The authors provide new insights and suggest avenues for future research into the drivers and implications of federal-level policy shifts towards Indigenous self-determination in health.

In “Strengthening policy for First Nations self-determination in heath: an analysis of problems, politics, and policy related to medical travel in the Northwest Territories,” Crystal Milligan, Stephanie Irlbacher-Fox, and Mark J. Dobrow (2023) discuss the challenges and barriers to medical travel within the Northwest Territories (NT). The authors highlight the challenges faced by the Gwich’in people and their experiences with accessing medical care. Drawing from Gwich’in medical travel stories and existing literature on health care access, the authors offer a new perspective on the issues surrounding medical travel in the NT and argue that current policies provide only partial access to care.

The third article, “Recognizing First Nations jurisdiction and authority over public health for the Sioux Lookout First Nations Health Authority” by Ariel Root, Natalie Hansen, Emily Paterson, Francine Pellerin, Lloyd Douglas, and Janet Gordon (2023) discusses the challenges faced by First Nations peoples in achieving positive health outcomes due to the enduring impacts of colonial laws and structures. It emphasizes the importance of First Nations control in developing community-led solutions to enhance overall wellbeing. The Sioux Lookout First Nations Health Authority was established to address these issues and implemented a First Nations-developed public health system called Approaches to Community Wellbeing, rooted in traditional teachings and practices. However, the authors note that there are obstacles due to the failure of federal and provincial legal systems to recognize First Nations sovereignty over health and to resolve jurisdictional ambiguities.

The fourth article, “Disrupting colonial narratives: (re)claiming autonomy and (re)affirm-ing traditional family structures through story in the Teme-augaming” by Robyn K. Rowe (2024) examines the profound impacts of land displacement, theft, and erasure of First Nations people in Canada, which have undermined their political, economic, cultural, linguistic, ancestral, and family formations. It argues that nation rebuilding is essential for sovereignty efforts and improving social and political conditions affecting health and wellness. Asserting sovereignty is closely tied to the autonomous assertion of land and resource rights. This article includes Indigenous storywork with a First Nations Elder and challenges colonially defined territorial boundaries in the Temagami region of Northeastern Ontario.

The fifth article, “Separating birth from community: colonialism and historical institutionalism in Indigenous pregnancy evacuation policies” by Sabrina Lee and Angela Mashford-Pringle (2024) examines the long-standing practice of evacuating pregnant Indigenous women from remote communities to urban centres for birthing in Canada, which, although not formalized as policy, has been customary for decades. The article highlights how this practice disrupts the connection between birth and community, land, ceremony, and Traditional Healing for Indigenous peoples. The authors suggest that historical institutionalism and Euro-Canadian epistemologies have perpetuated this norm, preventing significant change. They argue that Indigenous self-determination is essential for reforming Indigenous maternity care policies and addressing this systemic issue within health care systems.

The final article, “Examining policy shifts and transformations in Indigenous primary health care in Alberta, Canada” by Danika Goveas, Stephanie Montesanti, Susan Chatwood, and Lynden (Lindsay) Crowshoe (2024) explores the importance of transforming primary health care (PHC) to achieve health equity for Indigenous peoples in Alberta. It highlights fragmented, under-resourced, and disconnected PHC services within First Nations, Métis, and urban contexts, perpetuating existing health inequities. Despite advancements, more efforts are needed to address health priorities important to Indigenous peoples. The authors argue that future policy reforms should clarify the roles of federal, provincial, and Indigenous governments in coordinating PHC to ensure Indigenous representation in decision-making processes, and work towards decolonizing the health care institution to promote health equity.

In these powerful articles, readers will encounter a rich tapestry of stories, insights, reflections, analyses, and recommendations that shed light on the critical need for Indigenous-led and designed health policies, programs, systems, and services. In this context, several promising practices have emerged, offering valuable insights into the development of health policy and systems tailored to the unique needs and aspirations of Indigenous peoples.

Endnotes

¹ Jordan’s Principle is the focus of a forthcoming special issue of the journal.

References