Evaluation Of

Sagkeeng First Nation: Developmental Impacts and the Perception of Environmental Health Risks© by Brenda Elias John D. O’Neil Annalee Yassi Benita Cohen Department of Community Health Sciences University of Manitoba For additional copies of this report please contact CAHR office at 204-789-3250 April 1997 EVALUATION OF TRANSFERRED HEALTH SERVICES IN THE SHIBOGAMA FIRST NATIONS COUNCIL COMMUNITIES OF KINGFISHER LAKE, WAPEKEKA, AND WUNNUMIN LAKE Evaluation Project Coordinator Eddie Angees Shibogama Health Authority Wunnumin Lake and Sioux Lookout, ON Community Research Associates Clara Anderson, Wapekeka Rhoda Angees, Wunnumin Lake Mary Lou Winter, Kingfisher Lake Consultant Team T. Kue Young John D. O’Neil Shirley Hiebert Northern Health Research Unit Department of Community Health Sciences The University of Manitoba Winnipeg, MB March 1999 2 Table of Contents Acknowledgements Executive Summary 1. Introduction and Background 1.1 Transfer in the context of First Nations health care 1.2 Transfer in Ontario Region and the Sioux Lookout Zone 1.3 Evaluation and the Transfer Agreement 2. Design and Methods 2.1 Evaluation methods 2.2 Project coordination 3. Implementation of Transfer 3.1 Phased introduction of programs and services 3.2 Administrative and organizational structure 3.3 Financial management 3.4 Human resources 3.5 Relationship with Medical Services Branch 4. Impact of Transfer on Population Health Status 4.1 Demographic characteristics 4.2 Incidence of infectious diseases 4.3 Burden of chronic diseases 4.4 Injuries and social pathologies 5. Impact of Transfer on Health Services Utilization 5.1 Public health services 5.2 Treatment services 5.3 Mental health and social services 6. The Nursing Program 6.1 Nursing station expenditures 6.2 Issues in northern nursing practice 6.3 Transfer: the nursing perspective 7. The Patient Transportation Program 7.1 Administration and financing 7.2 Operational problems 8. Regional and Community Perspectives on Transfer 8.1 Relevance and importance of transfer 8.2 Difficulties in implementation 8.3 Benefits to communities since transfer 8.4 Problems experienced by communities since transfer 8.5 Improvements required for future transfer agreements 9. Conclusions and Recommendations Appendices i Acknowledgements Many individuals and organizations contributed to this evaluation. The design and implementation of the project is under the overall direction of the Shibogama Evaluation Committee and the evaluation committees in the communities: Shibogama Evaluation Committee: • Daisy Hoppe, Health Director, Shibogama Health Authority • Sheila Watt/Renata Bennett, Nursing Director, Shibogama Health Authority • Joseph Dooley, Medical Director, Sioux Lookout Zone Hospital • Rena Southwind, Executive Director, Sioux Lookout First Nations Health Authority • Chris Cromarty, Health Director, Wunnumin Lake Health Council • Paul Bighead, Health Director, Kingfisher Lake Health Council • Allan Brown, A/Health Director, Wapekeka Lake Health Council Kingfisher Lake Community Evaluation Committee: • Mary Lou Winter, Community Research Associate • Absolum Mamakwa, Community Member • Janet Mekanak, Elder • Hezekiah Sakakeep, Band Councillor - Health • Andrew Mamakwa, Resource Team Member • Elaine Steffanick, A/Nurse-in-Charge Wapekeka Community Evaluation Committee • John McKay, Member, Health Council • David Brown, Band Councillor - Health • Dora Winter, Chair, Health Council • James Brown, Member, Education Authority • Mary Anderson, Community Member Wunnumin Lake Community Evaluation Committee • Isiah Gliddy, Elder • Buddy Cromarty, A/Chair, Health Council • Maria McKay, Youth Representative • Annie Martin, Community Member Many other individuals provided advice, guidance and information to the evaluation team, notably: • Douglas Semple, Executive Director, Shibogama First Nations Council • Janet Gordon, Zone Director, Sioux Lookout, Medical Services Branch, Health Canada • Joyce Timpson, Clinical Coordinator, Shibogama Health Authority • Rosalie Davies, Director, Payahtakenemowin, Shibogama Health Authority • Selma Poulin, Director, Nodin Counselling Services • Mary Kakapetum, Transportation Clerk, Shibogama Health Authority ii Executive Summary • This evaluation covers the first five years of the transfer agreements between Medical Services Branch of Health Canada and the First Nations of Wunnumin Lake, Kingfisher Lake and Wapekeka, which commenced on January 1, 1994. The three communities are the only First Nations in the Sioux Lookout Zone which have sought and achieved transfer. • These communities in turn delegate certain centralized services to the Shibogama First Nations Council (SFNC), which established the Shibogama Health Authority (SHA). This is consistent with the practice whereby the SFNC provides technical support to locally based, locally managed, and locally controlled services. SHA receives its operating budget from contributions by the three communities. • The objectives of transfer, as set out in the transfer agreement, are to design health programs, establish health services and allocate funds according to community health priorities; ensure public health and safety by providing mandatory health programs; and strengthen and enhance accountability to community members. • SHA developed a comprehensive evaluation plan which integrates quantitative and qualitative methods, and provides for the opportunity for community strengthening and capacity-building. The Northern Health Research Unit (NHRU) of the University of Manitoba was contracted to conduct the evaluation, as well as to support and train an evaluation coordinator hired by SHA and research associates selected by the communities. • The evaluation used three methods of data collection: review of official statistics and reports, including annual reports from the health councils of the communities and audited financial statements; structured interviews of 52 key informants in Sioux Lookout and the communities, and a questionnaire survey of community members. Overall 479 questionnaires were received, representing a response rate of 78%. • With transfer, the three communities established health councils each headed by a health director. The health director are responsible for three key areas: nursing/CHR, resource team (for mental health and social services), and administration/finance. Wunnumin Lake also operates its own transportation program with a transportation manager. Nurses-in-charge and resource team coordinators also receive consultation and advice from the nursing director, clinical coordinator and director of Payahtakenemowin of SHA. • Between FY93/94 and FY98/99 the three communities received $4,389,231 (Wunnumin), $4,209,108 (Kingfisher) and $3,369,101 (Wapekeka) from MSB through the transfer agreements and their various amendments. In addition the communities accessed other sources of funding from federal and provincial agencies and programs. • It is difficult to compare expenditure level before and after transfer. Expenditures relating to Wapekeka and Kingfisher Lake before 1993/94, other than contribution agreements with the First Nations, cannot be separated from the total expenditures of the nursing stations in Big Trout Lake and Wunnumin Lake respectively, from where visiting nursing services originated. iii • While the ultimate test of the effectiveness and impact of a health program is whether it improves the health of the target population it is important to stress that the total size of the population of the three SHA communities is small (< 1,500), the rate of occurrence of most significant health events (eg. deaths, new cases of disease, etc) is very low and the duration of post-transfer follow-up (5 years) is short. Under such circumstances, it would be difficult to demonstrate that any observed trends are due to the direct result of the transfer initiative and not the year-to-year fluctuations expected by chance alone. • There is an encouraging trend in the decline in the rate of completed suicides and suicide attempts in SHA communities after transfer, compared to the general trend in the rest of the Sioux Lookout Zone. During 1987-93, 22% of all suicide attempts in the Zone occurred in SHA communities, compared to <10% during 1994-98. • A review of the health services provided under transfer indicates that in general the pre- transfer level of mandatory services has been maintained. In terms of usage of the nursing station, there has been a noticeable and steady increase in the number of patient visits. According to the community survey, nursing stations are heavily utilized, with less than 5% of respondents who did not use them at all in the past year, while more than 50% use them 5 or more times a year. • A major achievement of transfer in the Shibogama communities is the integration of health and social services within the same administrative structure and service delivery system. It pools the resources of several agencies and creates a client-oriented team at the community level. Wunnumin Lake has gone the farthest in incorporating also welfare services and home care. The resource team concept, however, is not yet fully implemented and some disparities still occur between different types of workers. There is still a substantial proportion of community members who do not believe or are uncertain that they have access to help when needed. • Nurses employed by SHA are generally enthusiastic about working in a First Nation- controlled nursing station. The high level of enthusiasm and team spirit they

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