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Module 2: Organization of Health Services

INHS 101

This module looks at the organization of health services. You will be introduced to an overview of the federal, provincial, civic, rural, and First Nations level of services. Websites are provided for most of the organizations so that you can find further information, reports, and research to inform your studies. You are also introduced to these services so that you know where to access grants, information, and service information for you, your clients, and your community. We then go through the history of Indian Health Services in the US. We then briefly look at how other countries work with Indigenous peoples in managing health and wellness. We look a bit at what’s going on in Australia and New Zealand. We wrap up the module by looking at the global health organizations and how they influence health worldwide.

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Health Services: Learning Objectives

Federal responsibilities

Policies and pertinent legislations

Jurisdictional issues

Health organizations in Canada

2

Health Services: National

Treaties have 3 possible interpretations:

Agreements between two or more nations

Contracts

Pieces of legislation

Treaties establish 2 things:

Outline fiduciary responsibility on part of the federal government

Outline the usufruct rights for First Nations people

3

Health Services: National

Health Canada is responsible for:

Setting and administering national principles

Delivering healthcare services to First Nations & Inuit peoples

Collaborate with provincial and territorial governments to maintain and improve First Nations and Inuit peoples’ health

http://www.hc-sc.gc.ca/hcs-sss/index-eng.php

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Indigenous Services Canada (ISC)

works collaboratively with partners to improve access to high quality services for First Nations, Inuit and Métis. Their vision is to support and empower Indigenous peoples to independently deliver services and address the socio-economic conditions in their communities.

https://www.canada.ca/en/indigenous-services-canada.html

 

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Health Services: National

Health care services for First Nations and Inuit peoples:

https://www.sac-isc.gc.ca/eng/1581895601263/1581895825373

Jordan’s Principle

Supporting Inuit children

Non-insured health benefits for First Nations and Inuit

Government of Canada actions to reduce anti-Indigenous racism in healthcare systems

Indigenous health management and initiatives

Indian Residential Schools resolution health support program

First nations and Inuit health information system (FNIHIS)

6

Health Services: Provincial/Territorial

Provincial/Territorial Gov’t is responsible for:

Administration and delivery of healthcare services

Fund healthcare services within their borders

Establish their own policy, legislation, and standards for the health system

https://www.canada.ca/en/health-canada/services/health-cards.html

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Health Services: Federal and Provincial

The above video is an explanation of Indigenous Health Policy in Canada. Submitted by Lakshmi Menon in September 2021 for CHL5523H Indigenous Health at Dalla Lana School of Public Health, University of Toronto

Click on the picture above. If you want to view it in the full screen, click on Slide Show above and then start from current slide. If it does not work you can cut and paste the link below and open in a web browser.

2:16 mins

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Health Services: Regional

Regional authorities are responsible for:

Establishing a regional health authority

Outlining responsibilities for managing and delivering services

CANADA’S REGIONAL HEALTH AUTHORITIES

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Saskatchewan Health Authority

The Saskatchewan Health Authority is the largest organization in Saskatchewan. SHA is responsible fo​r the delivery of safe, high quality health care for the entire province. The SHA work with other service providers to better co-ordinate health services across the province to ensure people receive the right care, in the right place, at the right time, and by the right provider, anywhere in Saskatchewan.

https://www.saskhealthauthority.ca/

Health Related Calls to Action: # 18-24 & # 55

https://www.saskhealthauthority.ca/sites/default/files/2021-09/SHA-TRC-Report-Calls-To-Action.pdf

10

Cultural Responsiveness Framework

Cultural responsiveness has been described as “respecting where people are from and including their culture in the design and delivery of services” or an “active process of seeking to accommodate the service to the client’s cultural context, values and needs.”

At its core, the Cultural Responsiveness Framework is meant to serve as a tool for respectful cross-cultural engagement and reciprocity between the two systems, where neither one controls but supports one another in common efforts to enhance the health and wellness of Saskatchewan First Nations peoples (p.9).

FSIN, 2021

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Federation of Saskatchewan Indian Nations (FSIN, 2021)

https://www.saskhealthauthority.ca/sites/default/files/2021-06/FSIN-cultural-responsiveness-framework.pdf

12

Health Services: Regional

All Nations Healing Hospital is an example of blending western-based services with local Indigenous ways of healing at a regional level.

Pasikow Muskwa Rising Bear Healing Centre’s philosophy is guided by the First Nations’ Leadership vision to ensure ALL are welcome, respected, and empowered in meeting their holistic needs in achieving optimal health and well-being.

A multidisciplinary team provides chronic disease management, outreach services, early screening and detection for kidney disease, satellite hemodialysis, independent hemodialysis and support for home dialysis.

Watch the video by clicking on the picture. To view it full screen, choose Slide Show, start from current slide. If it does not work, you can cut and paste this link in your web browser.

Pasikow Muskwa Rising Bear Healing Centre

3:01 mins

13

Health Services: Rural

Rural residents experience difficulties accessing health services

These difficulties are due to a number of reasons:

Distribution of physicians

Distribution of other healthcare professionals

Distribution of healthcare facilities

Underservicing of health-related services

Geographical location

Rural Indigenous populations face additional & unique health concerns

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Health Services: Rural

This video is from CBC News: The National

“Canada is struggling to provide health care to northern communities, according to one doctor who travels monthly to provide his services. Dr. Mike Kirlew says that the level of care his patients in northern communities have access to is not even close to what is available to other Canadians.”

The video depicts the experiences of northern community members and access to health services.

(13:53 mins)

15

Metis Health Services

Saskatchewan Health Authority Guiding Principles

Traditional First Nations and Métis approaches to wellness, including the use of traditional healers, medicine people, and Elders are recognized, respected, and promoted within the Saskatchewan Health Authority.

Addressing the issues facing First Nations and Métis communities requires a respectful and cooperative partnership between the community, it’s leadership and those trusted to provide health care.

As First Nations and Métis people, we have the right to control our health in regards to matters that are important to our communities, cultures, identities, traditions and languages.

To be an effective steward, we must be accountable for the resources and care of those we are entrusted to serve, and have the courage to do what is right.

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Programs and services geared to the needs of First Nations and Métis peoples include:

Four Directions Community Health Centre located in located in North-Central Regina promotes individual, family and community health and wellness.

Native Counseling Services respond to clients with an awareness of cultural and spiritual diversity, and is able to provide an alternative for clients seeking traditional First Nations and Métis approaches to health care.

Representative Workforce, in partnership with First Nations and Métis Relations, so that our workforce will reflect the community and the diversity of our clients.

Randall Kinship Centre offers programs to meet the needs of families with children and youth who have serious disruptive behaviour problems.

Harm Reduction is a program for injection drug users that also includes a recovery option.

Aboriginal Problem Gambling is sensitive to the needs of First Nations and Métis clients.

Al Ritchie Health Action Centre provides programs that meet the expressed health needs of area residents.

Health Services: USA

Different from other minority groups in that Native Americans / American Indians have a special political relationship with the federal government set forth in the constitution, treaties, statutes and court cases.

Tribes are sovereign – meaning they retained the right to govern themselves, make and enforce their own laws, and establish membership/citizenship

Any rights that were not expressly surrendered are still retained by the tribe

Now that we have reviewed Canada’s health services for Indigenous peoples. Let’s take a look to the south.

Indigenous people in the USA are also referred to in the literature as American Indians, Native Americans, and Alaskan Natives. In looking at specific legislation, statistics, legal cases, etc. you will often find the terms American Indians and Native Alaskans. Throughout this section I’m going to abbreviate American Indians and Alaskan Natives to AI/AN. I will also be using the term Indigenous people in the US as a more inclusive term when not referring to specific legislation or statistics.

A little more information on American Indians, Native Americans, and Alaskan Natives:

According to the 2010 census, the US population was 308,745,538 and American Indians and Alaskan Natives make up 1.2% of the population (approximately 1.9 million)

There are 566 federally recognized tribes each with their own traditions, history, and culture

Now that we have some of the statistics about Native Americans, its time to discuss the relationship between Indigenous peoples and the US government:

A couple big things that we need to keep in mind when looking at the relationship:

Different from other minority groups in that Native Americans / American Indians have a special political relationship with the federal government set forth in the constitution, treaties, statutes and court cases.

Tribes are sovereign – meaning they retained the right to govern themselves, make and enforce their own laws, and establish membership/citizenship

Any rights that were not expressly surrendered are still retained by the tribe

Treaties between Indigenous people and the European newcomers sought to secure peace, friendship, reciprocity, and later cede Indigenous title to the land. Treaties conducted with Indigenous groups prior to 1763 were primarily conducted to secure peace, as well as secure allies in times of need. As trade partners and allies, treaty partners were expected to help each other in times of need or crisis, including but not limited to food shortages, and aid in protecting each other from enemies.

As more and more settlers came to North America, more lands were needed. Tribal lands along the eastern coast and further inland were becoming populated with settlers pushing their way further west. In order to combat scrupulous land cessions the British restricted settlement by colonists beyond the Appalachian Mountains and established requirements that had to be met before Indigenous land could be purchased in the proclamation of 1763 (Calloway 2006). After the revolutionary war, the newly formed United States (1776) adopted and adapted parts of the proclamation, prohibiting unauthorized settlement or purchase of Indian lands by anyone other than the federal government. This established a clear relationship between the federal government and the Indigenous tribes.

Treaties between the United States and Indigenous tribes after the revolutionary war are still upheld as legally binding agreements between two equal parties (Getches et al. 2004). The treaties between the United States and the tribes established a trust relationship, in which the United States has a responsibility to the tribes. Any Indigenous rights that were not specifically surrendered were reserved by the tribe. The tribes retained their sovereignty, meaning their right to govern themselves, make and enforce their own laws, and establish membership / citizenship criteria. The purpose of negotiating treaties largely coincided with the policy era.

Additional articles added to treaties during the removal era include treaty provisions in terms of annuities, rations, and certain provisions such as medical care. Treaties negotiated during this time also reserve the tribes’ rights to hunt, fish, and gather. Treaties negotiated during the reservation period included many of these articles, but also included articles dealing with agriculture, education, medical services, the services of physicians, or the provision of hospitals for the care of Indian people. Any rights that were not expressly surrendered or given up in the treaty are still maintained by the tribe.

The treaties between the federal government and Indian nations serve as examples of the nation-to-nation agreements made. The federal government has a trust relationship with the tribes and serves as a protectorate. This does not mean that the tribes are not sovereign; this simply means that the tribes cannot sell land without federal permission and cannot declare war on other countries.

The trust relationship is also characterized by the fiduciary duty the federal government has to tribal nations. Under this definition the federal government has the duty to act in the best interests of the tribe. The terms of the treaties, however, did not always prove fruitful for the tribes who signed them. Certain problems with the negotiation of treaties include but are not limited to language, interpretation, legal jargon, vague terms, and representation. In addition to some of these problems, Indian tribes did not always have a choice in the negotiation process. For example after the Indian wars, terms of treaties were virtually imposed on tribes who had little choice but to agree to the terms implemented by the federal government.

Treaty negotiations between the tribes and the US government ended in 1871 after a rider was attached to an Appropriations Bill stating Congress would no longer pass or ratify treaties (The Indian Appropriation Act of March 3, 1871, 16 Stat. 544). This rider did not affect any treaties that were previously signed between the federal government and the Indian tribes. After this period the United States entered into agreements with tribes, rather than treaties. Treaties, as opposed to agreements, are the supreme law of the land, built on a nation to nation agreement (Deloria Jr. & Wilkins 1999; Deloria 2000; Deloria Jr. & Lytle 1984).

The end of treaty negotiations changed the relationship between tribal nations and the federal government. Tribes were not considered to be as powerful as they once were, and instead were seen as being largely dependent on the federal government.

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Health Services: USA

Relationship between Indigenous people in the US and the US Government

Trust relationship set forth in the constitution, treaties, statutes and court cases

Tribes are sovereign

The Indian Health Service, an agency within the Department of Health and Human Services  , is responsible for providing federal health services to American Indians and Alaska Natives. 

The IHS provides a comprehensive health service delivery system for approximately 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized tribes   in 37 states.

Historically, they suffer from disproportionately:

High rates of measles, small pox, and tuberculosis

Higher rates of diabetes

Higher rates of heart disease, stroke, renal failure, liver disease, & amputations

Higher rates of cancer, chronic diseases, & HIV

Higher rates of suicide and death from accidents

Lower life expectancy

The health care system in the United States does not provide universal health care to all. Even though the United States is legally responsible to provide health services, they are chronically under funded.

https://www.ihs.gov/newsroom/factsheets/

20

Health Services: IHS

The Indian Health Service (IHS) is the main health care provider & advocate for Indian Americans

The Snyder Act (1921)

The Snyder Act of 1921 (25 USC 13) and the permanent reauthorization of the Indian Health Care Improvement Act [enacted in 2010 as part of the Patient Protection and Affordable Care Act (P.L. 111-148)] provide specific legislative authority for Congress to appropriate funds specifically for the health care of Indian people. In addition, numerous other laws, court cases, and Executive Orders reaffirm the unique relationship between tribal governments and the federal government.

Goal of the IHS:

Uphold the federal government’s obligation to promote healthy Indian people, communities, and cultures

Protect inherent sovereign rights of the tribes

https://www.ihs.gov/

https://www.ihs.gov/newsroom/factsheets/basisforhealthservices/

21

Health Services: IHS Con’t

IHS has no blood requirement

IHS consists of hospitals, health centers, and health stations.

IHS runs urban health projects that provide health and referral services

Services delivered include:

Dental •Public health nursing

Preventative care •Health exams

Mental health •Drug and alcohol treatment

http://www.ihs.gov/newsroom/factsheets/quicklook/

22

Health Services: IHS

This video provides an overview of IHS and how a real time pandemic affected communities.

9:36 mins

After watching the video, what are your thoughts on IHS? Is the federal government living up to their obligation under the trust relationship? What are some of the challenges associated with the current system? What are some of the parallels and differences between the US and Canada in terms of Health Care services for Indigenous people? Aside from allocating more funds towards health services for Indigenous people, what else can the federal governments, in both Canada and the US, do to help improve the health outcomes of Indigenous people?

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Health Services: Australia

Prior to 1971, provincial, territorial, and federal governments managed Indigenous health

Indigenous people in Australia fought for Aboriginal Community Controlled Health Services (ACCHO)

ACCS’ are also known as Aboriginal Medical Services (AMS) or Aboriginal Health Services (AHS)

While the ACCHO’s are really positive, they still had to deal with a lack of funding

In 2009, a national campaign called on the government to improve health for Indigenous peoples.

24

Health Services: New Zealand

In 1840, the Treaty of Waitangi was signed, an agreement between the British Crown and Maori. It established British law in New Zealand and is considered New Zealand’s founding document and an important part of the country’s history.

In the 1990s, New Zealand went through major health service reforms

Establishment of Maori health care services

Development of cultural safety education

The results:

Promotion of Maori models of health

Maori cultural processes used as a basis for contemporary health services

Ideas of Maori self-sufficiency supported

Cultural safety courses offered to non-Maori health care providers

(Ellison-Loschmann & Pearce, 2006) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470538

Life expectancy is approximately 8 years less than that of non Maori

Major causes of death include heart disease, cancer, diabetes, stroke, intentional and unintentional injuries

More likely to smoke, 1.5 times more likely to be obese than non Maori adults

More likely to report mental health issues, such as depression and anxiety, and experience interpersonal violence

Maori people experienced various forms of racism and discrimination in the health care system, much like other Indigenous people in Canada, the US, and Australia.

For more information on Maori health, check out the New Zealand Ministry of Health’s website at http://www.health.govt.nz/our-work/populations/maori-health

To read more about the health of Indigenous peoples in Australia, Canada, New Zealand and the US, check out Pulver et al (2010) Indigenous Health – Australia, Canada, Aotearoa New Zealand and the United States – Laying claim to a future that embraces health for us all. World Health Report. Background Paper, No. 33.

The concept of cultural safety was born in New Zealand by Maori nursing students.

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Health Services: Global

In the last 50 years, major changes in international communities have occurred

Today, international communities and Organizations:

Deal aggressively with health issues on an international basis

Are better educated, more mobile, and more independent

Are less autonomous and more dependent on state funding

Due to the size and complexity of modern communities, long-term planning and international community organization is essential to using resources for health effectively

26

Health Services: WHO

World Health Organization (WHO) is most recognized international health organization

Planning for WHO coincided with United Nations charters in 1945

Purpose of WHO is:

Attainment of the best possible level of health for all peoples

Provide funding to improve the health work force and control diseases

Provide central technical services such as expert advisors and technical service personnel

The work of WHO is financed by member nations

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Health Services: WHO

Health is essential for people to reach their full potential. That’s why the World Health Organization works to make sure everyone everywhere has access to health services wherever and whenever they need them. WHO serves a unique role as the guardian of health. Watch this video to find out more.

2:02 mins

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Health Services: PAHO

The Pan American Health Organization (PAHO) was founded in 1902

PAHO is the oldest international public health agency

PAHO now serves as WHO’s regional office for the Americans

PAHO’s mission is to strengthen national and local health systems and improve health outcomes for all people in the Americans

https://www.paho.org/en/who-we-are

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Health Services: UNICEF

United Nations International Children’s Emergency Fund (UNICEF) is another widely recognized international health organization

UNICEF focuses on:

Child survival and development

Nutrition and environmental interventions

Basic education and gender equality

https://www.unicef.org/

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Health Services: Semi-Governmental

The quasi-governmental health organizations – organizations that have some official health responsibilities but operate, in part, like voluntary health organization – make important contributions to community health

Examples of quasi-official agencies are the American Red Cross, the National Science Foundation, and the National Academy of Sciences

31

Health Services: Non-Governmental

Non-governmental health agencies are funded by private donations or membership dues

There are thousands of these organizations

Created because there was unmet health needs

The agencies operate, for the most part, free from governmental interference

32

Health Services: Non-profit

Within non-profit health organizations, there are three different groups:

Voluntary health agencies

Professional health organizations/associations

Philanthropic foundations

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What’s next

Make sure to complete this module’s readings

Next module looks at Communicable and Chronic Diseases

Is anything due?

References

ABS (Australian Bureau of Statistics) 2002. Year book, Australia, 2002. ABS cat. no. 1301.0. Canberra: ABS.

ABS 2018. Estimates of Aboriginal and Torres Strait Islander Australians, June 2016. ABS cat. no. 3238.0.55.001. Canberra: ABS.

ABS 2019a. Cultural Identification. National Aboriginal and Torres Strait Islander Health Survey TableBuilder, accessed 7 April 2021.

ABS 2019b. Estimates and projections, Aboriginal and Torres Strait Islander Australians, 2006 to 2031. ABS cat. no. 3238.0. Canberra: ABS.

Data. Saskatchewan Centre for Patient-Oriented Research. (n.d.). Retrieved October 21, 2021, from https://www.scpor.ca/data.

Ellison-Loschmann, L., & Pearce, N. (2006). Improving access to health care among New Zealand’s Maori population. American journal of public health, 96(4), 612–617. https://doi.org/10.2105/AJPH.2005.070680

Health and Welfare, Advisory Commission on Indian and Inuit Health Consultation, Report, February, 1980, p. 4.

Government of Canada; Indigenous Services Canada. (2021, July 8). About the non-insured health benefits program. Government of Canada; Indigenous Services Canada. Retrieved October 15, 2021, from https://www.sac-isc.gc.ca/eng/1576790320164/1576790364553.

Government of Ontario, Ministry of Health and Long-Term Care. (n.d.). Community Health Centres. Health Services in Your Community – MOHLTC. Retrieved October 12, 2021, from https://www.health.gov.on.ca/en/common/system/services/chc/.

Jennissen, T. (1992). (rep.). Health Issues in Rural Canada. Political and Social Affairs Division. Retrieved from https://publications.gc.ca/Collection-R/LoPBdP/BP/bp325-e.htm#CONCLUDINGtxt.

Johnson, S. (2015). Jordan’s Principle and Indigenous children with disabilities in Canada: Jurisdiction, advocacy, and research. Journal of social work in disability & rehabilitation, 14(3-4), 233-244.

Publications – australian indigenous HealthInfoNet. (2020). Retrieved October 22, 2021, from https://healthinfonet.ecu.edu.au/key-resources/publications/42701/.

Quick look: Fact sheets. Newsroom. (2017). Retrieved October 21, 2021, from https://www.ihs.gov/newsroom/factsheets/quicklook/.

Saskatchewan Centre for patient-oriented research. Saskatchewan Centre for Patient-Oriented Research. (n.d.). Retrieved October 21, 2021, from https://www.scpor.ca/.

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