COMMENTARY HEALTH SERVICES

Delivering more equitable primary in Northern

T. Kue Young MD PhD, Susan­­ Chatwood BScN PhD

n Cite as: CMAJ 2017 November 13;189:E1377-8. doi: 10.1503/cmaj.170498

rimary care has featured prominently in national debates on what ails the Canadian health care system and what KEY POINTS holds the key to its sustainability. Most jurisdictions in • Residents of remote communities in Canada’s three northern PCanada have attempted reform in recent years,1 but territories experience substantial health disparities and do not reference to is conspicuously absent from the have the same access to health care as living in plethora of critiques and analyses. Primary care would be urban centres. enhanced in Canada’s northern and remote communities • Northern Canada’s widely scattered small communities cannot through incorporation of the values and knowledge of local and rely on , whether resident or visiting. Indigenous peoples into system planning. • Technological innovations, appropriate training, better Canadians in remote communities, particularly in the three coordination and communication, adoption of culturally based healing systems and development of environmentally northern territories, do not have the same access to health care as sustainable communities may help to address challenges. Canadians living in urban centres in the provinces. Surveys have • However, moving beyond “primary care” as services provided shown that in terms of the proportion of the population who have by physicians and other providers to the more comprehensive, a regular doctor, northerners are worse off than other Canadians, upstream and multisectoral concept of “,” with patients in experiencing the largest disparity.2 How- which is well aligned with Indigenous values and concepts of ever, primary care in Northern Canada is about more than services wellness, is critically important to advance . provided by family physicians. There are actually two primary care models in Northern Canada, one that exists within its regional cen- tres and capital cities, with family physicians as the entry point, vut by the Auditor General of Canada5 found staff turnover to be and another in remote communities, with nurses as the entry an intractable problem, alongside difficulties in recruitment and point. Most Indigenous people live in the remote communities, retention. However, a recent conference focusing on remote whereas non-Indigenous people live mainly in cities. The nurse- health care identified several promising innovations.6 These based system of primary care in remote northern communities is included use of remote presence technology in providing physi- supported by periodic visits and depends on community cian services from a distance and in the training of primary care health representatives, electronic health records, consultation ser- providers closer to home; land-based training of community vices, and a telecommunication and transportation system that and wider dissemination of self-care skills; central- links these health centres with regional and facilities in ization of the emergency evacuation response and clinical sup- southern Canada. The nurse-based system ensures round-the- port system; development of healing models that incorporate clock access to a primary care provider in remote communities.3 Indigenous values and are connected to the land; mutually Given the large number of small communities scattered over an respectful communication between the frontline and regional enormous land mass, primary care in these communities can centres; and culturally responsive and environmentally sustain- never rely on physicians, whether resident or visiting. Task shifting able architectural design of homes and communities that pro- (the redistribution of tasks among different categories of provid- mote healing and wellness. ers), which is a strategy used globally to meet the primary health Although different systems of care may ensure access to a care needs of underserved populations,4 has been in place in health care provider, health disparities continue to exist between Northern Canada for decades. However, little attention has been Indigenous and non-Indigenous populations in Northern Can- paid to assessing the performance of the task-shifting model of ada.2 Improvements in the health care system can be made at primary care in the Canadian context. the level of personnel and technology, but there is a need to There are many challenges to ensuring access to primary care move beyond the narrow definition of primary care as provision in northern communities. A recent review of health care in Nuna- of services by family physicians, nurse practitioners and other

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© 2017 Joule Inc. or its licensors CMAJ | NOVEMBER 13, 2017 | VOLUME 189 | ISSUE 45 E1377 COMMENTARY of theperformanceprimarycaresystemarestilllacking. needs of patients in terms of health care access, in-depth analyses data suggestthatthecurrentsystemmayhaveservedbasic parameters ofprimarycarereform.Althoughcurrentlyavailable disparities call for an urgent reframing of the goals and systems communities onhealthservicesplanninganddelivery. higher levelsofengagementwithIndigenousgovernmentsand advanced inthethreenorthern territories, there is stillaneedfor land claimssettlementsandpoliticalself-determinationhave tional knowledgeandculturallybasedhealingsystems.While Indigenous communitiesandorganizations,incorporatingtradi- other province-andterritory-wide Nations HealthAuthority inBritish Columbia offer amodel for Assembly ofFirstNations.Recentdevelopmentsinthe nous organizationssuchastheInuitTapiriitKanatamiand E1378 Declaration ofAlmaAtaonprimaryhealthcarein1978, icies toadvancehealth.Asoriginallyframedinthelandmark mary healthcare providers, and address the more comprehensive concept of pri- resources andenvironmentalconnection. balance, life control, education, material resources, social and haveexpandedtheconcepttoincludeculture,language, recognize theimportanceofsocialdeterminantshealth Northern Canada.CanadianInuit,FirstNationsandMetisfully with Indigenousvaluesandholisticconceptionsofwellnessin self-determination. TheprinciplesofAlmaAtaarewellaligned control ofprimaryhealthcareinthespiritself-relianceand aged toparticipateintheplanning,organization,operationand ple havearighttohealth,andcommunitiesshouldbeencour- that affecttheirhealth, ples calledforIndigenouscontroloftheinstitutionalsystems Toronto, Ont. Public Health (Chatwood), University of wood), Yellowknife,NT;DallaLanaSchoolof tute forCircumpolarHealthResearch(Chat- University ofAlberta,Edmonton,Alta.;Insti- Affiliations: School ofPublicHealth(Young), This articlehasbeenpeerreviewed. Competing interests:Nonedeclared. In Canada’snorthernterritories,frequentlyobservedhealth Over adecadeago,theRoyalCommissiononAboriginalPeo- by developingupstreamandmultisectoralpol- 10 aproposalendorsedbynationalIndige- health systemscontrolledby CMAJ 8,9 | NOVEMBER 13,2017 guarantors of the work. guarantors ofthework. sion to be published and agreed to act as ­of theauthorsgavefinalapprovalver- cally forimportantintellectualcontent.Both article and Susan Chatwood revised it criti design ofthearticle.KueYoungdrafted uted substantiallytotheconceptionand Contributors: Bothoftheauthorscontrib- 7 allpeo- |

10. References an alliance. in NorthernCanadadependsontheirwillingnesstoformsuch can bringaboutbroadsystemchangetoadvancehealthequity their consequences.Developmentofinnovativesolutionsthat stand thecausesofinequalityandhavepersonallyexperienced ship withpatient(i.e.,community)representativeswhounder- Indigenous leaderstosupportprimarycarereforminpartner- with theimmediatedemandsofacutecare,theymustally system inNorthernCanada.Eventhoughtheyarechallenged

VOLUME 189 4 3. 6. 5. 7. 2. 1. 9. 8. . Primary careprovidersaregatekeeperstothehealth Young getting valueformoney?HealthcPolicy2016;12:59-70. Young (accessed 2017Jan.16). Available: Health careservices—Nunavut.Ottawa:OfficeoftheAuditorGeneral; ( 2008. global recommendationsandguidelines.Geneva:WorldHealthOrganization; Task shifting:rationalredistributionoftasksamonghealthworkforceteams: its circumpolarneighbours.CMAJ2011;183:209-14. eng/1100100014597/1100100014637 (accessed2017Oct.4).­­­­ Canada; [updated2010Sept.15]. to people, nation to nation. Gatineau(QC):IndigenousandNorthernAffairs Highlights fromthereportofRoyalCommissiononAboriginal Peoples people critical populationhealthapproach.HealthPlace2009;15:403-11. Alma-Ata, USSR; Declaration ofAlma-Ata. munities: reportonaninternationalconference.BMCProc2016;10(Suppl6):. Young Policy 2013;9:12-25. Hutchison Richmond Determinants_Report.pdf (accessed2017Oct.4). 2014. Social determinantsofInuithealthinCanada. Ottawa: Tapiriit Kanatami; almaata_declaration_en.pdf?ua=1 (accessed2017Apr.5). accessed 2017Jan.16). Available: Available:

TK, TK, TK , Chatwood Chatwood B. www.oag-bvg.gc.ca/internet/English/nun_201703_e_41998.html Chatwood CA, Reforming Canadianprimarycare—don’tstophalf-way. | ISSUE 45 Ross www.who.int/healthsystems/TTR-TaskShifting.pdf?ua=1&ua=1 https://www.itk.ca/wp-content/uploads/2016/07/ITK_Social_ - 1978 Sept.6–12. NA.

S, S. S ualberta.ca Correspondence to:KueYoung,kue.young@ Based PrimaryHealthCare(TT6-128271). of HealthResearchteamgrantinCommunity- research supportedbyaCanadianInstitutes Funding: , Ford Health careintheNorth:WhatCanadacanlearnfrom The determinantsofFirstNationandInuithealth:a Marchildon International ConferenceonPrimaryHealthCare, J, et al. Available:

This commentaryisbasedon G Transforming healthcareinremotecom- Available: . ’s North: Are we https://www.aadnc-aandc.gc.ca/ www.who.int/publications/ Healthc 2017.