Ontario’s Indigenous Population Health System Delivery: A Call to Action
Emily Porchak, MSc (Candidate) Health Information Science
Western University
Indigenous health care system delivery in Ontario is a complex and underexamined issue. Indigenous peoples in Canada are composed of the First Nations, Inuit and Metis (Mattison et al., 2016) and have had a dreadful relationship with healthcare in Ontario. For example, Indian hospitals segregated Indigenous people while performing poor quality care throughout the period of residential schools in the early 1900s (Lux, 2010). I stand with others who have put forward that Indigenous people should at least be involved in, but ideally have control of, their healthcare delivery to meet their cultural, locational and health needs (Nguyen et al., 2020). An understanding of health policies within the last six years relating to healthcare service delivery for Indigenous peoples, with a focus on impacts in Ontario, helps to clarify what changes remain to achieve Indigenous control over their healthcare delivery.
2015: First Steps Toward Health System Collaboration
After the federal Truth and Reconciliation Commission report concluded in 2015, it was evident that relationships with Indigenous peoples needed improvement at all levels of government (Government of Canada, 2022). The Nishnawbe Aski Nation (NAN) called a Declaration of Public Health Emergency for First Nations across NAN territory in rural and remote Northern Ontario intending to increase their self-determination over healthcare services (Nishnawbe Aski Nation, n.d.). In 2016, Ontario committed to investing $222 million each year for three years, then $104.5 million each year after to give Indigenous people culturally appropriate care that would improve their health outcomes through Ontario’s First Nations Health Action Plan (Government of Ontario, 2016). This would be implemented and evaluated with Indigenous partners but rely heavily on the federal government for support.
In 2017, the Charter of Relationship Principles Governing Health System Transformation in NAN Territory was signed by the Federal Minister of Health, Ontario Minister of Health and Grand Chief of NAN to transform healthcare delivery for First Nations communities through a new responsive system-wide health approach (Government of Canada, 2017). It should be noted that the Charter is for relationship-strengthening only and is not legally binding. The Charter highlights the importance of creating a new approach for health service delivery that is culturally safe and timely for all Indigenous peoples regardless of location (Government of Canada, 2017). Many stakeholders are involved in this type of transformative change including the federal government, provincial government, NAN chiefs, community workers including health workers, Elders and members of the community. Collaboration is needed from government bodies and all stakeholders to perform this level of transformative change.
In early 2018, the Ontario government launched the Ontario’s First Nations Health Action Plan. This initiative intended to expand primary care to have sixteen Indigenous-governed community teams across Ontario, including remote areas, to provide culturally safe care and funding for ten Indigenous-led healing and treatment centers (Government of Ontario, 2018). This is a needed commitment for progress. But requires implementation and still does not explicitly state the role of Indigenous peoples in the oversight of health system delivery. Members of the Indigenous communities were concerned by these policies as it was clear that the Wynne-Liberal government wanted to reduce Indigenous peoples' health inequities. But there is still no commitment to remove the gap altogether (Lui, 2016). A commitment to end these inequities would require a clear law to encourage follow-through that is co-produced with Indigenous peoples, as substantial change requires resources, implementation and evaluation.
Government Turnover Changes Commitments
In 2018, the progress made on Indigenous healthcare would face a major obstacle with the election of a Conservative government that had a different view towards Indigenous health priorities (Zambito, 2019). The Conservative government “is turning back the clock” by centralizing healthcare decision-making power to reduce costs so a few people make the decisions for everyone in Ontario (Talaga, 2019). All the work with the trilateral Charter agreement was not cancelled, as the new Ontario Health Minister reached out to NAN recognizing their role in healthcare system delivery (Talaga, 2019). But NAN had not heard from them again in 2019. Essentially, the political turnover halted all progress made on NAN healthcare delivery. In 2020 and 2021, the NAN Grand Chief, federal, and provincial health ministers re-committed to action against racism experienced by Indigenous peoples in health care (Heintzman, 2020). This is reminiscent of earlier instances where NAN and other Indigenous people were similarly in positions where oral commitments to action are made without the accompanying policy commitments needed to guarantee transformative change.
Long-term systematic change is limited by the turnover of political leadership. Wylie et al. (2020) found that the policy commitments held by the Liberal Minster of Health through the trilateral agreement were not reciprocated with the Conservative Ontario Minister of Health. This leads to more meetings and short-term changes only. It is hard to create long-lasting transformative change without sustained relationships between stakeholders (Wylie et al., 2020). Later in 2021, NAN signed another trilateral agreement with Canada and Ontario to commit to working together to establish a First Nations health service delivery system within the NAN territory (Indigenous Services Canada, 2021). This is an extremely repetitive process of gathering stakeholders to sign a commitment to work together on future policy changes.
A Small Step in the Right Direction
There is one recent change I would like to highlight. The People’s Health Care Act, 2019 looks at making Ontario’s health system patient-centered with a section to “recognize the role of Indigenous peoples in the planning, design, delivery and evaluation of health services in their communities.” The Act mentions engaging Indigenous people in the planning of health services, consulting Indigenous communities before creating health plans and having at least one Indigenous health council advise about health service delivery issues (The People’s Health Care Act, 2019). This formally creates a role for Indigenous people in their healthcare, but this role is advisory at best. The conversations and signed trilateral Charters would allow Indigenous peoples to take charge of their own healthcare but this Act does not specify that. It merely says that there will be input from Indigenous people when creating health system delivery plans. From where I stand, consultation with Indigenous peoples is a minimum and authority over their care is still needed.
Recommendations
Synthesizing the information over the last decade on health system delivery for Indigenous peoples in Ontario leads me to propose several recommendations. First, there is a lack of collaboration between government parties. This paper highlighted the progress made by the Ontario Liberal party in signing the Charter, which was halted when the Conservative party was elected where they signed a very similar agreement with the same stakeholders. This process is time-consuming and limiting. So, I suggest a law solidifying a non-partisan entity being responsible for Indigenous healthcare in Ontario. This non-partisan body would encourage conversations to continue, in a timely fashion, regardless of which party was in power. Second, there needs to be a reconciliation between the patchwork system in place between the provincial and federal governments. Both levels of government need to take ownership of their policies rather than spread blame. Third, the limited involvement of Indigenous peoples in their health service delivery needs to be rectified. Charters have been signed indicating that NAN would be a partner but the People’s Health Care Act, 2019 limited Indigenous people’s role to an advisory capacity. More needs to be done to give Indigenous people a partnership with the government that is bidirectional. These are my recommendations to allow Indigenous people control, not just influence, over their health service delivery systems.
References
The People’s Health Care Act, S.O. (2019, c. 5 – Bill 74). Retrieved from: https://www.ontario.ca/laws/statute/s19005#BK4
Government of Canada. (2017). Charter of Relationship Principles for Nishnawbe Aski Nation Territory.
Government of Canada. (2022). Truth and Reconciliation Commission of Canada. https://www.rcaanc-cirnac.gc.ca/eng/1450124405592/1529106060525
Government of Ontario. (2016). Ontario launches $222 million First Nations Health Action Plan. https://news.ontario.ca/en/release/38954/ontario-launches-222-million-first-nations-health-action-plan
Government of Ontario. (2018). Ontario Taking Action on Indigenous Health Care. Ontario Newsroom.
Heintzman, M. (2020). Commitment to Action Needed After Meeting on Racism Against Indigenous Peoples in Health Care. Nishnawbe Aski Nation.
Indigenous Services Canada. (2021). Indigenous health care in Canada.
Lui, S. (2016, May 25). First Nations leaders optimistic but cautious about Ontario’s indigenous health care plan. CBC News.
Lux, M. K. (2010). Care for the ‘Racially Careless’: Indian Hospitals in the Canadian West, 1920–1950s. Canadian Historical Review, 91(3), 407–434. https://doi.org/10.3138/chr.91.3.407
Mattison, C., Doxtater, K., & Lavis, J. (2016). Care for Indigenous peoples. In J. Lavis (Ed.), Ontario’s health system: Key insights for engaged citizens, professionals and policymakers (pp. 349–373). McMaster Health Forum.
Nguyen, N. H., Subhan, F. B., Williams, K., & Chan, C. B. (2020). Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review. Healthcare, 8(112), doi:10.3390/healthcare8020112.
Nishnawbe Aski Nation. (n.d.). Health Transformation. Nishnawbe Aski Nation. https://www.nan.ca/health-transformation/about/
Talaga, T. (2019, July 5). Indigenous health care needs won’t be served by Ford government’s plan. The Toronto Star.
Wylie, L., McConkey, S., & Corrado, A. M. (2020). Colonial Legacies and Collaborative Action: Improving Indigenous Peoples’ Health Care in Canada. International Indigenous Policy Journal, 10(5). https://doi.org/10.18584/iipj.2019.10.5.9340
Zambito, G. (2019). A Plan for the People - A critical discourse analysis of the campaign platform and victory speech of Premier Doug Ford (2018-2019) (Version 1). Toronto Metropolitan University. https://doi.org/10.32920/ryerson.14655297.v1
