Public Health in First Nations Communities:

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Public Health in First Nations Communities
Communication and Collaboration as Key to
Success Valerie Gideon, Ph. D. Regional
Director, First Nations and Inuit Health, Ontario
Region February 8, 2008
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Discussion Points

• Unique Public Policy Challenges
• Understanding First Nations Wholistic Policy
  Development
• Flexibility Current State of FN Public Health
  Service Delivery
• Innovation Examples of Success
• Key Elements of Collaboration
• Accomplishments To Date
• AFN
• FNIHB
• Priorities for Ontario
• Critical Success Factors

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Unique public policy challenges

• Dynamic, complex policy environment often also
  characterized by some of the most acute needs in
  the country
• Comprehensive policy response required that can
  effectively manage required change and drive
  innovation
• First Nations Wholistic Policy and Planning Model
  grounded in self-government
• This reality demands
• Understanding
• Flexibility, and
• Innovation

N.B. Based on AFN Friends of Social Policy
Presentation and statistics from the First
Nations Regional Longitudinal Health Survey,
2002-03 (RHS)
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Public Policy Challenges Understanding

• Treaties
• Analogies contain the spirit, oral understanding
  and essence
• Two-row wampum and Covenant chain
• Constitutional Supremacy
• Constitution Act inclusion of section 35
• Constitution is now supreme to all other laws
  including Indian Act and the federal 91- 24
  powers
• First Nations governments are not equivalent
  to Canadian stakeholders
• Nation to Nation recognition sought First
  Nations-distinct approach required
• First Nations governments have bylaw-making
  authority to protect the public health and safety
  of their members, in accordance with the Indian
  Act
• Links to Flexbility diverse peoples with
  diverse languages and cultures

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FN Wholistic Policy and Planning Model
Public Policy Challenges Understanding

• Published in 2005, revised for WHO in 2007
• Based on social determinants model
• Incorporates First Nations ways of knowing
• Grounded in recognition and reconciliation of
  rights and title
• Supports innovation and investment
• Reform claims policies, self-government policy
  and processes
• End budget caps and replace with fiscal transfers
• Capacity to achieve accountability and clear
  information governance

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FN Wholistic Policy and Planning Model (ctd)
Public Policy Challenges Understanding

• Evidence confirms
• RCAP (1996) increases in spending on human
  resource and institutional development,
  improvement in economic and living conditions,
  and structural changes to land claims and treaty
  processes would lead to long-term benefits and
  reduced public costs
• UN Development program (1999) on capable
  governments capacity development requires an
  enabling environment to succeed
• Harvard Project (1998) concluded that
  reinforcement of tribal sovereignty should be the
  central thrust of public policy
• Cornell (2006) again references three key
  features self-rule, capable governing
  institutions, and cultural match

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FN Wholistic Policy and Planning Model (ctd)

• Key Elements
• Community Core
• Lifespan
• Self-government
• Determinants of well-being
• Relations within outside Community

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Unique public policy challenges Flexibility

• 1979 Indian Health Policy
• Health Canadas First Nations and Inuit Health
  Branch (FNIHB) mandate primary care and public
  health on-reserve and non-insured health benefits
  to all Status Indians regardless of where they
  live within Canada
• There are 134 First Nations communities in
  Ontario and 4 Zones
• Moose Factory 6 communities
• Southern Ontario 27 communities
• Sioux Lookout 31 communities
• Thunder Bay 65 communities
• There are five regional FN organizations and 22
  tribal councils

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Current State of Funding/Programs
Public Policy Challenges Flexibility

• Four different types of funding arrangements
  negotiated between the FN Band and FNIH ON
• Set contribution agreement
• Transitional contribution agreement
• Flexible agreement
• Flexible transfer agreement
• About 50 of First Nations communities in Ontario
  Region have negotiated transferred health service
  agreements for primary care and public health
• The Government of Ontario provides a number of
  community support, health promotion programs, as
  well as secondary and tertiary care funded
  through Canada Health and Social Transfers and
  other dedicated provincial funds

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FNIH PROGRAM AUTHORITIES

Health Governance/ Infrastructure Support
Community Programs
Health Protection
Primary Health Care
NIHB
AUTHORITY
Environmental Health Research
Communicable Disease Control
Chronic Disease/Injury Prevention
Mental Health Addictions
Children Youth
COMPONENTS (Clusters)

• Health Planning Management
• Health Consultation Liaison
• Integration Adaptation of Health Services
• Management Delivery of Hospital Services
• Security Services
• Health Human Resources
• Support Services for Nursing
• Health Research
• e-solutions
• FN/I Health Careers

• Community Primary Health Care (PHC)
• Oral Health Strategy (OHS)
• FN/I Home Community Care (HCC)

• Building Health Communities (BHC)
• Brighter Futures (BF)
• National Native Alcohol Drug Abuse
  (NNADAP)
• Youth Solvent Abuse Program (YSAP)
• FN/I Tobacco Control Strategy (TCS)
• Indian Residential Schools

• Environmental Health Programs
• Environmental Health Research Programs

• Aboriginal Diabetes Initiative (ADI)
• Nutrition Physical Activity Promotion
  (NPAP)
• Injury Prevention (IP)

• Vaccine Preventable Disease (Immunization)
• Blood Borne Disease and Sexually
  Transmitted Infections (HIV/AIDS)
• Respiratory Infections (Tuberculosis)
  Programs

• Aboriginal Head Start On-Reserve (AHSOR)
• Canada Prenatal Nutrition Program
  (CPNP) FN/I Component
• Fetal Alcohol Spectrum Disorder (FASD)
• Maternal Child Health

PROGRAMS ACTIVITIES
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Five-Year Budget Trend for FNIH ON
Public Policy Challenges Flexibility
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FNIH ON 2007/08 Budget
Public Policy Challenges Flexibility
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Acute needs
Public Policy Challenges Flexibility

• Poorer health status, largely due to neglects in
• Health determinants, water quality, housing,
  education
• Inter-generational impacts of residential schools
  and child welfare
• Access to timely and quality care
• Supporting FN governance and capacity
• Need for standards and enforcement (i.e., health
  protection)
• Gaps in programming and access to services
• Lack of sustainability threatens program
  integrity
• Recruitment/retention of health professionals
• Jurisdictional confusion in roles and
  responsibilities
• Lack of sufficient data and comprehensive
  surveillance

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FN Children are at Risk
Public Policy Challenges Flexibility

• First Nations children and poverty
• 1 out of 4 FN child lives in poverty, compared to
  1 in 6 Canadian children
• One third of FN children live in overcrowded
  homes
• Over half of FN children are obese or overweight
• The rate of FN children with disabilities (1 in
  8) is double the Canadian rate
• Direct correlation between lower family income,
  overcrowding, poor nutrition, lower levels of
  physical activity and educational achievement
  among First Nations children

Data from the First Nations Regional Longitudinal
Health Survey (RHS), 2002/03
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Unique public policy challenges Innovation

• 95of FN Children in the Sioux Lookout Zone
  require general anaesthetic intervention for
  Early Childhood Caries

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Unique public policy challenges Innovation

• DMFT Decayed, Missing, Filled Teeth among 3-5
  yr olds
• DMFT Index Toronto1.1
• DMFT Index non-First Nations2.5-2.8
• DMFT Index First Nations Southern Ontario3.5-4.8
• DMFT Index First Nations SLZ Ontario10-13.7

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Childrens Oral Health Initiative
Public Policy Challenges Innovation

• COHI is a Health Canada project designed to
  prevent and control tooth decay and other oral
  diseases in young First Nations and Inuit
  children
• COHI targets pregnant women, children from birth
  to seven years and their parents and/or
  caregivers
• 1998-1999 pilot projects in partnership with
  staff of the Kenora Area Health Access Centre,
  and the North Western Health Unit
• 2005 Both units receive a 3-year agreement to
  deliver COHI to 23 local First Nations
  communities
• Currently funding is available for only two
  communities in Sioux Lookout Zone Fort Severn
  and Muskrat Dam
• 2 communities to be added in Sep 08 with the
  projection of adding another four communities in
  Sep 09

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KO Telemedicine
Public Policy Challenges Innovation

• KOTM was established in 2001 by the Keewaytinook
  Okimakanak tribal council in Sioux Lookout Zone.
• KO Telemedicine delivers clinical, educational
  and administrative services via video
  conferencing to First Nations communities in
  Northern Ontario.
• There are currently 25 remote First Nations
  communities in the Sioux Lookout Zone
  participating

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Key Elements of Collaboration

• Collaboration through joint processes
• Drive and manage change based on understanding,
  evidence and commitment to innovation
• Clear policy objectives and targets based on
  wholistic policy considerations
• Removing administrative barriers and advancing
  best practices aimed at community resiliency
• Supported by solid information and capacity
• FN self-determination applied to data and
  research

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Accomplishments to Date

• 2003 Naylor Report FN public health
  infrastructure as least developed
• 2005 AFN Public Health Framework and 3 pilots,
  incl. Kenora Chiefs
• 2005 FN Pandemic Wholistic Planning Pilots
• 2006 FNIHBs A Federal Public Health Strategic
  Plan for First Nations On-Reserve
• 2006 AFN-Health Canada Bilateral Innovation Plan
• 2006 AFNs FN Client Registry Phase 0 Project
• Ontario Pandemic Preparedness Plan Chapter
  specific to FNs
• 2007 Chiefs of Ontario Tripartite Public Health
  Initiative
• Tripartite Public Health Relationship Framework
• Knowledge Management Advisory Committee for
  Panorama deployment

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AFN Public Health Framework Components
Source Joint AFN-FNIHB Presentation to CPHA,
September 2007
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Jurisdictional Clarity
AFN Public Health Framework Jurisdiction
Tribal Council, in collaboration with
communities authority must be respected to
choose the following options for public health
services
Option 2 Hiring of MOH and other public health
staff (incl. more resources for self-governing FNs
Option 3 Collaborate with other Tribal Councils
Option 4 Cost sharing of programs with
Provincial RHA or District Health Council

• Option 1 Purchase services

Option 5 Status Quo
Establishing strategic linkages with the Province
and Territory
Source Joint AFN-FNIHB Presentation to CPHA,
September 2007
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FNIHB Public Health Strategic Plan

• Vision An integrated, comprehensive on-reserve
  public health system for First Nations that
  promotes and protects health, prevents injuries
  and disease, and responds to on-reserve public
  health emergencies.
• FNIHBs strategic vision for public health sees a
  shift from a provider of public health services
  to that of a funder.
• Shift program and policy design and
  decision-making to First Nations
• Integration with P/T public health systems
  (leverage expertise seamless delivery of
  services)
• Principles
• On-reserve First Nations public health
  programming and services will be consistent with
  FNIHBs three pillars for First Nations health
  (improved outcomes, better integration, greater
  First Nations control)
• Grounded in the principles of equity and
  comparable health services
• Based on enforceable authorities
• Sufficient surge capacity and integration/collabor
  ation with P/T public health systems
• Driven by standards and evidence
• Supported by reliable health-related information
  and data.

Source Joint AFN-FNIHB Presentation to CPHA,
September 2007
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FNIHB Public Health Strategic Plan
Source Joint AFN-FNIHB Presentation to CPHA,
September 2007
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Accomplishments to Date (ctd)

• AFN-FNIHB common premises and potential actions
• Health determinants
• FN participation in, and control over, service
  design and delivery
• Linkages with existing (and evolving) provincial
  systems
• Outstanding roles and responsibilities and
  standards on reserve
• Key gaps in FN public health (e.g.
  data/surveillance, public health human
  resources).

Source Joint AFN-FNIHB Presentation to CPHA,
September 2007
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Concrete and Ongoing Actions

• AFN and Health Canada Task Group
• Created December 2006 to explore key issues of
  mutual concern, particularly the development of
  cross-jurisdictional agreements and legislative
  options for on-reserve public health.
• Public health pilot projects in three First
  Nations communities (including Kenora Chiefs
  Advisory)
• Governance and service delivery models
• Community health assessments
• Data/infostructure requirements
• Innovations (e.g. First Nations client registry)
• Evaluation
• Tripartite MOU with British Columbia and First
  Nations Leadership Council (June 20007)

Source Joint AFN-FNIHB Presentation to CPHA,
September 2007
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Priorities for Ontario

• Explore tripartite collaboration
• COO/FNIH/MOHLTC Public Health Relationship
  Framework
• COO/FNIH/MOHP Health Promotions Strategy
  Development
• Weeneebayko Health Integration Agreement
• Sioux Lookout Four Party Agreement and Anishnabe
  Health Plan
• Explore delegated authority for FNIH Community
  Medicine Specialists in Ontario HPPA
• First Nations Pandemic Technical Working Group
• Seek opportunities for collaboration in direct
  public health services delivery with PHUs, e.g.
• Childrens Oral Health Initiative
• Environmental Health
• Surveillance (Panorama and beyond, e.g. vital
  stats, client registry, Regional Health Survey
  etc)
• Telemedicine (KOTM)

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Critical Success Factors

• Clear and ongoing communication
• Supporting community-based planning, service
  delivery and healing initiatives
• Working together to address sustainability
  challenges
• Putting the case forward
• Developing partnerships
• Finding new ways to attract and retain health
  providers

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Welalin!

• Contact
• Valerie Gideon, Ph.D.
• Regional Director
• First Nations and Inuit Health, ON Region
• Health Canada
• [phone]
• Valerie_Gideon_at_hc-sc.gc.ca