Indigenous health care in Canada
Canada's health care system
The organization of Canada's health care system is largely determined by the Canadian Constitution, in which roles and responsibilities are divided between the federal, provincial and territorial governments. Generally, provinces and territories have primary jurisdiction over the administration and delivery of health care services. This includes setting their own priorities, administering their health care budgets and managing their own resources. The federal government exercises a role in health care primarily through the use of the federal spending power. The Canada Health Act, Canada's legislation imposing national standards on provincial health care insurance plans as a condition of accepting a federal contribution to the cost of those plans, is an example of the use of the federal spending power.
In order for provinces and territories to receive their full federal cash contribution under the Canada Health Transfer, provincial and territorial health insurance plans must meet national principles established under the Canada Health Act (such as public administration, comprehensiveness, universality, portability and accessibility). The act requires that all medically necessary hospital, physician and surgical dental services (such as, insurable health services) be covered by provincial or territorial health care insurance plans for all eligible residents of the province or territory, including Indigenous Peoples. Although the act establishes broad, national principles that govern the Canadian health care insurance system as a whole, it does not set standards for the delivery of insured health services, such as timeliness or the quality of care received. It is the responsibility of the provinces and territories to manage the operation of their health care systems. Provinces and territories also provide a wide range of services that fall outside the Canada Health Act’s definition of insured health services, such as dental and vision care services, residential long-term care and chronic home care services. Provinces and territories do so at their discretion, and on their own terms and conditions. As such, the scope of services, level of coverage, and eligibility criteria vary from one province or territory to another.
With respect to health care for Indigenous peoples, which include First Nations, Inuit and Métis, the federal, provincial and territorial levels of government share some degree of jurisdiction. The Canadian health system is a complex patchwork of policies, legislation and relationships. Indigenous peoples are included in the per capita allocations of funding from the federal fiscal transfer and are entitled to access insured provincial and territorial health services as residents of a province or territory. Indigenous Services Canada funds or directly provides services for First Nations and Inuit that supplement those provided by provinces and territories, including primary health care, health promotion and supplementary health benefits.
Indigenous Services Canada also funds or directly provides certain health care services to First Nations communities and funds the provision of certain community health programs for Inuit living in Inuit Nunangat. This is in addition to federal funding provided to territorial governments. Indigenous Services Canada also funds non-insured health care benefits to eligible First Nations and recognized Inuit regardless of where they live in Canada. Health Canada and the Public Health Agency of Canada provide funding for programs that target, in part, Indigenous peoples who live in urban settings or in northern communities. The Public Health Agency of Canada is also responsible for promoting and protecting the health of all Canadians, which includes Indigenous peoples, regardless of where they reside and offers an array of grants and contribution funding aimed at promoting health, as well as preventing and controlling chronic diseases, injuries and infectious diseases. Federal funding for First Nations and Inuit health services is provided through annual appropriations and is subject to discretionary increases or reductions by the federal government. This is in contrast with the main federal transfer to provinces and territories for health (that is, the Canada Health Transfer), which is protected in legislation. For Métis, off-reserve First Nations and non-status First Nations, services and benefits are primarily provided for by provinces and territories.
Provinces have broad powers under the Constitution in relation to the provision of health care to all individuals in the province, and territories enjoy powers of a parallel scope. Acting under these authorities, provinces and territories have enacted legislation governing matters such as the regulation of health care professionals. Provinces and territories provide universally accessible and publicly insured health services to all residents, including First Nations, Inuit and Métis.
A coordinated approach to address the health needs of First Nations, Inuit and Métis, and health care delivery among all levels of government including Indigenous governments, remains an ongoing challenge. Improved clarity and a shared understanding of the role of various levels of government is needed, including for Métis, off-reserve First Nations and urban Inuit populations.
Indigenous health in federal, provincial and territorial legislation and policy
Provincial and territorial legislation
Many provinces and territories have enacted legislative provisions recognizing matters such as the value and role of Indigenous groups in the planning and delivery of health services in their communities or the importance of culture and traditional healing practices. For example, some provincial and territorial legislation:
- highlights the importance of partnerships with Indigenous groups (YT)
- seeks to identify and address the health needs of particular groups within the population, including Indigenous peoples (BC)
- recognizes the values and role of Indigenous groups in the planning and delivery of health services in their communities or notes that the Minister could enter into agreements with Indigenous organizations and bodies (BC, AB, SK, ON, NS, NB, NU)
- ensures Indigenous representation on various health-related boards, committees and regional health authorities (NB, YT)
- provides that self-government agreements shall prevail in a conflict (NL, YT)
- includes provisions related to traditional healing practices (PEI, YT, NU) or recognition that Indigenous midwives should be exempt from control specified under the code of professions (MB, ON, QC, PEI, YT, NU); Ontario further extends this exemption to traditional healers
- states that culture should be taken into account during mental health assessments, for example, consultation with an Elder or cultural advisor (NWT, NU)
- exempts traditional Indigenous spiritual, cultural practices or ceremonies from regulations under tobacco control acts (BC, NWT)
- references role of Indigenous people in health information, privacy and management and/or notes that the province can disclose health information to an Indigenous government for the development of health programs and services (MB, PEI, YT, NWT)
- includes provisions to negotiate additional jurisdiction (AB, SK, ON, QC, NL, NB) or provisions to make bylaws to promote the health, safety and welfare of the residents within a defined area and to enhance Indigenous control over issues such as health (AB)
Self-governing First Nations, Inuit and Métis governments
Canada recognizes that First Nations, Inuit and Métis have an inherent right of self-government protected by section 35 of the Constitution Act, 1982. Canada recognizes that First Nations, Inuit and Métis have the right to govern themselves in relation to matters that are internal to their communities, integral to their unique cultures, identities, traditions, languages and institutions, and with respect to their special relationship to their land and their resources. Canada also recognizes that the inherent right to self-government may find expression in different ways, including through treaties and through agreements with federal and provincial governments.
Negotiated agreements put decision-making power into the hands of First Nations, Inuit and Métis governments who make their own choices about how to deliver programs and services to their communities. Negotiated agreements can also serve to better define the roles and responsibilities for program service and delivery. However, not all self-government agreements include health. For those that do, some examples of health related provisions include:
- an Indigenous government may make laws and/or has jurisdiction with respect to health services
- an Indigenous government may make laws and/or has jurisdiction with respect to traditional healing services, including maintenance of the practice and training of persons providing the traditional health services (for example, traditional healers)
- self-government negotiations shall address, and self-government agreements may include, matters related to health
- an Indigenous government is responsible for the administration of health services
In Quebec, Yukon, Newfoundland and Labrador, provincial and territorial legislation contains provisions related to existing self-government agreements, thereby clarifying the roles and responsibilities of these provinces and territories in health in the areas included in these self-government agreements.
Promising models and emerging pathways
With the 1979 Indian Health Policy and the 1988 Health Transfer Policy framework, First Nations and Inuit have realized enhanced control of health services. While self-government and land claim agreements have also created unique models and can set out law-making authority in many areas including health, there are many emerging trends in Indigenous health transformation, jurisdictional coordination and collaborative processes, which are helping to provide some coherence to Canada's complex health care system.
In Quebec, the health care needs of Nunavik Inuit and James Bay Cree are served through unique structures under the James Bay and Northern Quebec Agreement. These are co-funded by federal and provincial governments, managed by First Nations and Inuit authorities (the Cree Board of Health and Social Services of James Bay and the Nunavik Regional Board of Health and Social Services), and linked to the provincial health care system. Quebec legislation (Chapter S-5—An Act respecting health services and social services for Cree Native persons, 1991) gives the health minister the ability to exercise their power to work collaboratively with citizens within the territory of James Bay to improve health services and infrastructure within the territory. The act also ensures the rights of citizens within the territory to receive fair, equitable and, in some cases, specific health services of their choosing.
While more administrative in nature, similar co-funding arrangements by federal and provincial governments also support Indigenous health authorities in Saskatchewan. The Athabasca Health Authority serves several First Nations and Métis communities, and the Northern Inter-Tribal Health Authority serves nearly half of all First Nations within that province.
In British Columbia, a new era in First Nations health was forged in 2011 with the signing of the British Columbia Tripartite Framework Agreement in First Nation Health Governance. This tripartite agreement created a new province-wide First Nations Health Authority in 2013 with a direct leadership role for the design, delivery and management of health programs and services for First Nation communities in British Columbia. The tripartite partners work closely together to improve health outcomes for British Columbia First Nations communities through a First Nations health governance structure that addresses health and other inequities experienced by First Nations and works to identify opportunities for stronger coordination with provincial programs and services.
In other parts of Canada, including Manitoba, Ontario and Quebec, the Government of Canada is supporting First Nations-led institutions and organizations to increase their control over the design and delivery of First Nations health services and to advance Indigenous cultural safety and self-determination in health care. These health transformation projects aim to improve health outcomes and access to services for First Nations. Each project is unfolding in a unique way depending on the priorities of First Nations communities. With federal funding support and guidance, efforts are underway to create organizational capacity, engage community members to identify health priorities, create provincial and federal partnerships, explore and develop governance and service models, and work towards service delivery improvements on the path to a full transfer of control. This work has resulted in some promising developments:
- A tripartite Memorandum of Understanding was signed in 2019 by the First Nations of Quebec and Labrador Health and Social Services Commission, Canada and the province of Quebec that committed the partners to work towards a new health and social services governance model.
- In 2021, the Nishnawbe Aski Nation (NAN) signed a trilateral statement with Canada and the province of Ontario, committing to work together in partnership to support the establishment of a First Nations health services delivery system in NAN Territory. NAN has actively worked with their communities to identify key health priorities requiring immediate action in conjunction with exploring new models of health service delivery that will bring services closer to home and build capacity in northern communities to access and deliver more culturally responsive services.
- The Manitoba Keewatinowi Okimakanak has established the Keewatinohk Inniniw Minoayawin, which is an aggregated northern First Nations led-health entity, who are exploring new innovative primary care services models tailored specifically for northern communities and preparing to assume the responsibility for service delivery of programming.
- The Southern Chiefs' Organization and Canada signed a Memorandum of Understanding to establish a new health governance model focused on equitable and culturally appropriate health care for First Nations in southern Manitoba.