Access to Health Services As a Social Determinant of First Nations, Inuit

SOCIAL DETERMINANTS OF HEALTH ACCESS TO HEALTH SERVICES AS A SOCIAL DETERMINANT OF FIRST NATIONS, INUIT AND MÉTIS HEALTH health services is, however, not equally nor universally available to all Canadians (Greenwood, de Leeuw, & Lindsay, 2018; Horrill, McMillan, Schultz, & Thompson, 2018). Most notably, Indigenous peoples 1 continue to experience barriers to health care, resulting in significant and ongoing health disparities compared to other Canadians (Browne, 2017; Cameron, del Pilar Carmargo Plazas, Santos Salas, Bourque Bearskin, & Hungler, 2014; Goodman et al.,

© Credit: iStockPhoto.com, ID 484068969 © Credit: iStockPhoto.com, 2017; Greenwood, de Leeuw, Lindsay, & Reading, 2015; Office Canada’s universal health care financial or other barriers” of the Auditor General, 2015). system is widely considered to (Government of Canada, 1985; be among the best in the world amended 2017, p. 5). Having This fact sheet will explore how and a source of pride and health reasonable and equitable access accessibility, availability and for many Canadians (Martin to universal health services acceptability of health services et al., 2018). The primary facilitates earlier diagnosis, have indirect and direct impacts objective of this system is to lowers mortality and comorbidity on Indigenous peoples’ health “protect, promote and restore rates, and leads to improved and health outcomes. Within the physical and mental well- physical, mental, emotional, these three areas, complexities being of residents of Canada and social outcomes. Widely related to colonialism, geography, and to facilitate reasonable recognized as an important health systems, health human access to health services without determinant of health, access to resources, jurisdictional issues,

1 The terms ‘Indigenous’ and ‘Indigenous peoples’ are used here to refer to the First Nations, Inuit and Métis peoples of Canada, as defined in Section 35 of the Canadian Constitution of 1982. ‘Aboriginal’ and ‘Aboriginal peoples’ are used when reflected in the literature under discussion. Wherever possible, culturally specific names are used.

sharing knowledge · making a difference partager les connaissances · faire une différence ᖃᐅᔨᒃᑲᐃᖃᑎᒌᓃᖅ · ᐱᕚᓪᓕᖅᑎᑦᑎᓂᖅ communications, cultural safety, of colonialism (Allan & Smylie, Indigenous peoples (Boyer & and traditional medicines will be 2015). Indigenous peoples’ Bartlett, 2017). These historic addressed, as they each influence historic experiences, including examples, together with negative how Indigenous peoples view relocation of Inuit to southern contemporary interactions with and experience health care in hospitals and sanatoria for health care providers, have Canada. The fact sheet will the treatment of tuberculosis resulted in many Indigenous conclude by providing strategies and treatment received in individuals having a pronounced and innovations for improving the often inferior, racially- mistrust of and apprehension in Indigenous peoples’ access to segregated, Indian hospitals accessing health services, which health services. have left enduring impacts ultimately impacts their health on how they perceive medical and well-being (Browne et al., The current health disparities professionals and the mainstream 2011; Horrill et al., 2018; Lavoie, and inequitable access to health healthcare system (Lux, 2016). 2018; Logan McCallum & Perry, care experienced by Indigenous The continued coercion of 2018). peoples in Canada must be Indigenous women into tubal conceptualized within the context ligation underscores the ongoing of past and present manifestations institutional injustices faced by

The current health disparities and inequitable access to health care experienced by Indigenous peoples in Canada must be conceptualized within the context of past and present manifestations of colonialism (Allan & Smylie, 2015). © Credit: iStockPhoto.com, ID 472711634 © Credit: iStockPhoto.com,

2 Accessibility of health accessibility of health services Data from the 2012 Aboriginal across all geographic regions; Peoples Survey (APS) showed services however, the challenges are that Inuit face similar challenges. more acute in rural, remote and Even though 70% of Inuit in Accessibility can be understood northern communities. The rural Nunangat had been seen by a as “the availability of good health and remote location and small medical professional (primarily services within reasonable reach population size of communities a physician or nurse), only 23% of those who need them and in these regions can make it had a regular medical doctor of opening hours, appointment challenging to recruit and retain and 14% indicated they had systems and other aspects of health professionals, leaving experienced unmet health care service organization and delivery many communities with critical needs (Wallace, 2014). Amongst that allow people to obtain the shortages of medical personnel the most common reasons given services when they need them” (Huot et al., 2019; Mew et al. for unmet health care needs was (Evans, Hsu, & Boerma, 2103, 2017; Oosterveer & Young, that the health service was not p. 546). Indigenous peoples do 2015). These communities available in the area (25%) or at not have equitable access to typically rely on non-resident the time required (15%). health services compared to the health professionals who fly into general Canadian population communities for short durations due to geography, health system to see patients (Nelson & Wilson, Indigenous peoples deficiencies, and inadequate 2018; Oosterveer & Young, 2015; health human resources. Wallace, 2014). For First Nations experience specific living on reserve, long wait lists One’s location of residence and lack of available doctors or challenges related to determines one’s access to nurses pose significant barriers the accessibility of timely and localized health to receiving health care (First services. Indigenous peoples Nations Information Governance health services across live in urban centres, as well as Centre, [FNIGC], 2018). Other all geographic regions; in rural, remote and northern barriers to accessing health care communities across Canada. cited by First Nations adults however, the challenges According to Statistics Canada relate to Non-Insured Health are more acute in rural, (2017), approximately 80% of Benefits (NIHB), including “costs Métis live in urban centres; close not covered by the NIHB, lack remote and northern to half (44.2%) of registered of knowledge around NIHB First Nations people live on coverage, and NIHB denial of communities. reserve, with the remainder coverage” (FNIGC, 2018, p. 20). living off-reserve; while the Prohibitive transportation costs majority (72.8%) of Inuit also pose a significant barrier to continue to live in Nunangat.2 accessing health care (FNIGC, Indigenous peoples experience 2018). These types of barriers specific challenges related to the can lead to unmet health needs.

2 Inuit Nunangat is comprised of the Inuvialuit Settlement Region (Northwest Territories), Nunavut, Nunavik (Northern Quebec), and Nunatsiavut (Northern Labrador).

Access to health services as a social determinant of First Nations, Inuit and Métis health 3 FIGURE 1: INUIT MEDICAL TRAVEL MAP

Source : Inuit Tapiriit Kanatami (ITK), (2014, p. 32). Reproduced with permission courtesy of ITK, 2019.

Longer wait times to see health 2015; Patterson, Finn, & Barker, Edmonton, Winnipeg, Ottawa or care providers and specialized 2018; Wallace, 2014). Lavoie Montreal (Figure 1). According medical professionals can delay and colleagues (2015) stress to King et al. (2019), this the diagnosis of illnesses, result that while medical relocations extensive and expansive travel in less continuity of care, and can be a one-time event taking “render[s] the healthcare costs reduce the effectiveness of place over a period of hours or in these communities some of health services overall (Horrill days, the reality is that for many the most expensive in world” et al. 2018; Huot et al., 2019). Indigenous peoples, “medical (p. 3). Indigenous peoples can Given the lack and shortage ‘relocation’ is a misnomer,” as the experience financial hardships, of health professionals within back and forth “circuit” between loneliness, emotional stress, Indigenous communities, many the home and urban settings and elevated anxiety and individuals are transported for health care can become “a fear associated with medical to urban and southern-based permanent feature of peoples’ relocations, which may delay hospitals for medical emergencies, lives” (p. 296). recovery (Cameron et al., 2014; hospitalization, appointments Huot et al., 2019). Due to these with medical specialists, diagnosis Given the lack of accessibility issues, some Indigenous peoples and treatments, often leaving to health services, the patient may be reluctant to seek help behind families and support journey for Inuit can include when they experience symptoms, networks for extended periods lengthy travel between their resulting in a delayed diagnosis of time (Huot et al., 2019; Mew northern home communities and treatment. In fact, research et al., 2017; Oosterveer & Young, to southern hubs such as has shown that Indigenous people

4 are more likely to be diagnosed can have tragic health outcomes, services (Hwang, 2001). These at a later stage of a disease than as evidenced by the experience include the inability to provide non-Indigenous people, thus of Brian Sinclair, an Anishinaabe proof of insurance coverage, the contributing to poorer health man who was sent to Winnipeg’s inability to afford prescription outcomes and higher mortality Health Sciences Centre for a medication, mental illness or rates (Lavoie, Kaufert, Browne, & treatable bladder infection. In this substance abuse issues, and a O’Neil, 2016). case, Mr. Sinclair actively sought health care system that does out healthcare services, yet after not provide adequate treatment. Living in an urban centre can waiting thirty-four hours in the Collectively, these barriers provide better access to a range emergency waiting room without can result in the neglect of of healthcare services. However, being seen by a physician, he personal health issues. This is studies suggest that Indigenous was discovered dead. The denial particularly worrisome given the peoples may experience multiple of care for Mr. Sinclair can be overrepresentation of Indigenous and intersecting challenges in attributed to anti-Indigenous peoples amongst the homeless accessing urban health care racism and stereotyping, whereby population in Canada. They are services, including racism and he was seen as homeless and “10 times more likely to access discrimination, long wait lists, drunk rather than as a patient homeless emergency shelters and culturally unsafe care in need of and deserving of care than non Indigenous people, (Cameron et al, 2014; Goodman (Allan & Smylie, 2015; Brian representing approximately 30 et al., 2017; Logan McCallum & Sinclair Working Group, 2017; percent of all shelter users,” yet Perry, 2018; Smylie, Firestone, Logan McCallum & Perry, 2018). they represent approximately Spiller, & Tungasuvvingat Inuit, five percent of the Canadian 2018). These experiences can With elevated admissions population (Employment and result in perceptions that the to hospitals at rates that are Social Development Canada, health system is “uncaring and approximately five times greater 2018, p.3). However, these disrespectful to Indigenous than the general population, numbers can fluctuate widely clients, in effect denying them homeless Indigenous peoples among cities (Brandon et al., care” (Nelson & Wilson, 2018, in urban centres face unique 2018). pp. 23-24). These barriers to care challenges in accessing health © Credit: iStockPhoto.com, ID 508952990 © Credit: iStockPhoto.com,

Access to health services as a social determinant of First Nations, Inuit and Métis health 5 Since the 1960s, the federal government has adopted the position that health services are provided to First Nations in Canada “as a matter of policy only for humanitarian reasons and not due to any Aboriginal or Treaty rights”

(Lavoie et al., 2016b, p.8). © Credit: iStockPhoto.com, ID 584483132 © Credit: iStockPhoto.com,

Availability of health Since the 1960s, the federal Indians living off reserve, Inuit government has adopted the living outside their traditional care services position that health services territories, and Métis receive are provided to First Nations medical care from provincial and The availability of health services in Canada “as a matter of territorial governments which occurs when there is a “sufficient policy only for humanitarian deliver universal health services supply and appropriate stock reasons and not due to any to all Canadians. Since 1989, the of health workers, with the Aboriginal or Treaty rights” federal government has promoted competencies and skill-mix to (Lavoie et al., 2016b, p.8). The the devolution or transfer of match the health needs of the First Nations and Inuit Health responsibility for health programs population” (Global Health Branch (FNIHB) of Indigenous and services to communities Workforce Alliance, 2019). As Services Canada funds and through several mechanisms, discussed in the previous section, delivers community-based including funding agreements there is a dearth of health care health promotion and disease established in accordance with workers and services in some prevention programs, home and the Health Transfer Policy,3 regions of Canada, which community care, and programs self-government agreements, disproportionately impacts the to control communicable diseases as well as Indigenous Regional health outcomes of Indigenous and address environmental Health Authorities. As of 2008, peoples. In addition, there are health issues, as well as hires 89% of eligible First Nation and differences and discrepancies over 800 nurses and home care Inuit communities had or were in funding and programs for workers to work directly in First in the process of transferring First Nations, Inuit and Métis, Nations and Inuit communities responsibility (Lavoie, 2018). compounded by jurisdictional (Indigenous Services Canada Twenty-two self-government complexities and ambiguities. [ISC], 2018). Registered/Status agreements have been

3 See Indigenous Services Canada. (2005).

6 negotiated, giving 43 Indigenous federal programmes, provincially and to provide equitable funding communities law-making provided services, and highly and access to health, education authority to determine their bureaucratised add-ons together and social services, with a fifth priorities in key areas, including continue to fail to meet the non-compliance order issued in health (Crown-Indigenous needs and constitutional rights of February 2018 (First Nations Relations and Northern Affairs Indigenous people” (p. 1729). Child & Family Caring Society Canada, 2018). Some Indigenous of Canada, 2018). The Canadian regional health authorities have Jurisdictional barriers have led government has been working also emerged with higher level 4 to lengthy disputes between to address these inequities, responsibilities. In 2001, the various levels of government over committing $382.5 million Northern Inter-Tribal Health who has financial responsibility towards a Jordan’s Principle Authority (NITHA) was for particular health services Child-First Initiative, with established, providing culturally- for Indigenous peoples. The 171,000 requests for First Nations based third level services for 33 case of Jordan River Anderson children already approved as part First Nations in Saskatchewan underscores the inequity of health of this initiative (Government (NITHA, 2019a). In 2013, the service provision for Indigenous of Canada, 2018). Ultimately, precedent-setting First Nations peoples and children living on ongoing jurisdictional disputes, Health Authority (FNHA) reserve. A Cree child from the funding inequities and structural assumed responsibility from Norway Cree House Nation discrimination raise “questions FNIHB for the administration in northern Manitoba, Jordan about where responsibilities [lie] of health care programs and was born in 1999 with complex for the ‘implicit social contract’ services for 203 First Nations health issues. He died in 2005 guiding Canada’s vision of communities across British in a Winnipeg hospital at the equitable health care,” and how Columbia (FNHA, n.d.-a). age of five after waiting two this affects the health and well- years for federal and provincial being of Indigenous peoples Decades of complex, ambiguous governments to resolve the (Greenwood et al. 2018, p. 1647). and fragmented jurisdictional issue of who should pay for the issues, however, continue to result necessary specialized care in his Likewise, the jurisdictional in frustration, confusion, unmet home community (Chambers & limitations that fail to recognize health care needs and, most Burnett, 2017; Jordan’s Principle Métis identity and rights have concerning, higher mortality Working Group, 2015). On resulted in ongoing health and morbidity of Indigenous February 26, 2016, a landmark disparities among the Métis peoples (Greenwood et al., 2018; ruling of the Canadian Human (Chartrand, 2011; Martens et Lavoie et al., 2015). As stated Rights Tribunal (HRT) called on al., 2010). While Métis have by Martin and colleagues (2018) the Government of Canada to access to mainstream services, “[a] dizzying array of services in end racially discriminating against little or no attention has been the health-care system, including 165,000 First Nations children paid to their specific cultural or

4 There are three levels of health services. First level services are those provided in the community directly to community members. Second level services are provided primarily by higher level Indigenous authorities such as multi-community bands and Tribal Councils, and typically include program design, implementation and administration, supervision of first and second level staff, clinical support, consultation, and advice and training. Third level services are provided directly to second level partners and include disease surveillance, communicable disease control, health status monitoring, epidemiology, specialized program support, research, planning, education, training and technical support (NITHA, 2019b). Few Indigenous communities have responsibility for third level health services.

Access to health services as a social determinant of First Nations, Inuit and Métis health 7 geographical needs. On April acceptability of health services is in the provision of their 14, 2016, the Supreme Court of based on the fundamental shift health care (FNHA, n.d.-b; Canada (SCC) ruled its judgment in the power imbalances between Hobgood, Sawning, Bowen, in Daniels v. Canada, that patients and their care providers, & Savage, 2006; Lavoie et al., “Métis and non-status Indians and the way in which health 2013). are “Indians” under s. 91(24) of care is delivered to improve the Constitution Act (1867).” their health outcomes. Several Indigenous concepts of health However, it remains unclear as to dimensions of health services and well-being include a balance whether or how this judgement are foundational for Indigenous between mind, body, spirit and may impact the extension of peoples’ health and well-being. emotion; as well as living a good federally-funded healthcare to Culturally safe, appropriate life in harmony, reciprocity and Métis and non-status Indians and patient-centred care are relationship with other human currently provided to First interrelated concepts that have beings and the natural world. As Nations and Inuit (Lavoie, 2018). gained credence as fundamental such, there is a need to include for Indigenous peoples’ health cultural and traditional practices Acceptability of health care. These concepts incorporate and options in addition to, or several key elements: complementary to, biomedical care services models of health (Browne et al., 1. health services are perceived 2016; Tagalik, 2018; Truth and The acceptability of health as being free from bias, Reconciliation Commission of services can be understood as discrimination and racism; Canada [TRC], 2015). Patient- a “people’s willingness to seek 2. the unique and holistic health centred care reframes the services” because of perceptions care needs of Indigenous dynamics of top-down health they are effective and health care peoples are respected and care decision-making to focus providers are responsive to them met; on a patient’s agency and ability and free of social and cultural 3. and Indigenous peoples are to communicate and manage biases (Evans et al., 2103, p. 546). collaborators with health decisions around self-care. For Indigenous peoples, the providers as active agents This includes considerations

Indigenous concepts of health and well-being include a balance between mind, body, spirit and emotion; as well as living a good life in harmony, reciprocity and relationship with other human beings and the

8 for traditional healing and plain language and culturally a major restructuring to make approaches. Finally, the concept appropriate health education patient engagement and cultural of trauma- and violence informed resources, culturally sensitive safety a priority and core care is increasingly informing and empathetic personal contact, component of the organization” care for marginalized individuals as well as by acknowledging in order to improve their access who have experienced varying and respecting Indigenous to healthcare (Ringer, 2017, forms of violence with traumatic family structures, taking time p. 214). Acknowledging their impacts on an ongoing basis to establish relationships with prominent role as “gatekeepers (Browne et al., 2016). This patients, reflecting on one’s to the healthcare system,” nurses concept involves care that is behaviours and beliefs in have also adopted a strategy of respectful and affirming, with interactions with patients, and practicing within a cultural safety health providers who recognize actively involving patients in approach to improve Indigenous the intersecting health effects decision-making about their care peoples’ access to healthcare of violence and other forms of (Jennings, Bond, & Hill, 2018; (Horrill et al., 2018, p. 6). inequity, understand the social Shahid, Finn, & Thompson, context of health, and work to 2009). These facilitators are Indigenous control over the ensure that patients are not re- foundational to applying cultural design and administration of traumatized by their encounters safety in health care settings, and health services is recognized with the health system. improving Indigenous peoples’ as central to ensuring cultural access to healthcare services. safety in health care provision Good communication between in their communities (Cameron health care providers and patients Given that Indigenous peoples’ et al., 2014; Horrill et al., 2018; is central to the acceptability interactions with health providers Ringer, 2017). The movement of health services. Good have been shaped by experiences towards cultural safety and communication helps reduce the of unsafe care, lack of respectful humility in health services stress that Indigenous patients or compassionate treatment, delivery to Indigenous peoples may feel when they do not racism, and discrimination is also gaining traction on a speak either English or French (Cameron et al., 2014; Horrill et broader scale. For example, the as their primary language; it al., 2018; Ringer, 2017), the Truth FNHA has developed separate allows them to communicate and Reconciliation Commission declarations of commitment specific health questions, needs of Canada (2015) called on all on cultural safety and humility or concerns; and it allows them levels of government to “provide in health services delivery to to fully understand the nature of cultural competency training First Nations peoples in British their illness or diagnosis, their for all health-care providers” Columbia, which has been signed treatment directives, and how to as integral to closing the health by health regulators, Emergency follow them, including the use gaps between Indigenous and Management Services, of medications and prescriptions non-Indigenous peoples (p. 323). Providence Health Care, the BC (Cameron et al., 2014; Office of Cultural competency and safety Deputy Minister of Health, and the Languages Commissioner training has since been taken up the CEOs from each of BC’s six of Nunavut, 2015; Oosterveer by a number of health institutions health authorities (FNHA, 2017a, & Young, 2015). Good and organizations. Serving b, c, d). communication can be facilitated 16,000 Cree living in Northern through use of Indigenous Quebec, the Cree Board of translators, patient navigators, Health and Social Services of Indigenous health workers, James Bay (CBHSSJB), “began

Access to health services as a social determinant of First Nations, Inuit and Métis health 9 Strategies and availability of appropriate health healthcare. Jurisdictional issues services” (TRC, 2015, p 322). must also be resolved, including Innovations for government compliance with Improving Indigenous There have been repeated the 2016 Canadian Human calls to close the health gap Rights Tribunal ruling to end Peoples’ Access to between Indigenous and non- racial discrimination against Health Services Indigenous peoples in Canada. First Nations children, and true To do so, the intersecting and ongoing investment in their The Truth and Reconciliation determinants of health that health and well-being. Until these Commission identified the need impede Indigenous health disparities diminish, access to to address health inequities as outcomes must be addressed, health services will continue to be critical to the reconciliation including access to housing, clean a concern for Indigenous peoples. process. Specifically, Call water, food security, education to Action #19 urged that and employment, among others Key approaches to ensuring measurable goals be established (Browne et al., 2016). Current that Indigenous peoples’ access to “identify and close the gaps health structures, policies, and to health care is optimized, in health outcomes between systems must be transformed comparable and equitable to non- Aboriginal and non-Aboriginal so that Indigenous peoples Indigenous Canadians include: communities… [including] the receive equitable access to

Indigenous control over the design and administration of health services is recognized as central to

ensuring cultural safety in ID 801637286 © Credit: iStockPhoto.com, health care provision in their communities

(Cameron et al., 2014; Horrill et al., 2018; Ringer, 2017).

10 © Credit: iStockPhoto.com, ID 513473609 © Credit: iStockPhoto.com,

∙∙ committing to end ∙∙ engaging with Indigenous ∙∙ developing strategies for the jurisdictional issues, peoples to understand and recruitment and retention primarily through equitable develop health care practices of Indigenous and non- funding and ending inter- that are meaningful to them, Indigenous health human governmental disputes including traditional health resources for on-reserve, that lead to poorer health practices and medicines rural, remote and northern outcomes for Indigenous (Browne et al. 2016); communities (Vogel, 2019; peoples (Greenwood et al., ∙∙ emphasizing community Nader et al. 2017; Oosterveer 2018; Lavoie, 2018); ownership and authority over & Young, 2015). ∙∙ training professionals across health care services (Davy, all public health disciplines Harfield, McArthur, Munn, & and specializations in the Brown, 2016, Browne et al., delivery of culturally safe 2016); care, including actively ∙∙ encouraging students in dismantling racism, health care fields to seek out discrimination, and negative placements in rural, remote, stereotyping of Indigenous northern and on-reserve peoples (Browne et al. 2016; Indigenous communities Horrill et al. 2018; Nader, (Coke, Kuper, Richardson, & Kolhdooz, & Sharma, 2017; Cameron, 2016); and Smylie et al., 2018);

Access to health services as a social determinant of First Nations, Inuit and Métis health 11 Innovations All Nations, Healing Hospital San’yas Indigenous Cultural (ANHH) Safety Training A number of innovations are underway across Canada that seek Located in Fort Qu’Appelle, the A training program provided by to improve the health status of ANHH is owned and operated the Provincial Health Services Indigenous peoples. Examples of by the 15 First Nations of the Authority in BC to enhance a few include: File Hills Qu’Appelle Tribal cultural safety knowledge Council and Touchwood Agency and skills for professionals Aboriginal Health Access Tribal Council. Affiliated with and organizations working Centres (AHACs) the Regina Qu’Appelle Health with Indigenous peoples and Region, the health care centre communities. The program also A network of ten Indigenous delivers a range of acute, hosts a national Indigenous community-led, primary health palliative care, emergency Cultural Safety Learning Series services, women’s health and through webinars. care organizations across Ontario, serving Indigenous peoples in midwife services, and laboratory sanyas.ca/health-authorities/ urban, rural, northern and on-and and radiology services that are provincial-health-services -off-reserve communities. holistic, culturally-safe, patient- centred, and available in the five allianceon.org/aboriginal- different languages of the region. Conclusion health-access-centres fortquappelle.com/health- This fact sheet provided an emergency/all-nations- Akausivik Inuit Family Health overview of ongoing challenges healing-hospital Team - Medical Centre in the accessibility, availability and acceptability of health My Child, My Heart A health centre that provides service provision to Indigenous culturally appropriate primary peoples in Canada, with a view A community-based program care for Inuit living in Ottawa. to identifying opportunities for provided in the community of addressing these challenges, aifht.ca Pinaymootang, Manitoba that and thus improving their allows First Nations children health and well-being. Indeed, Alberta Health’s ‘virtual’ living with complex medical advancing this important social public health TB clinic needs to receive the care they determinant of health requires need in their own community. challenging manifestations of Established in 1999 as part of nog.ca/wp-content/ ongoing colonialism, improving a restructuring of Alberta’s TB uploads/2018/10/Module-1- health systems and health program, the ‘virtual’ clinic Appendix-B-Niniijaanis-Nide- human resources, addressing serves all non-major metropolitan Parent-Tool-Kit.pdf jurisdictional ambiguities, and on-reserve First Nations providing equitable funding for tuberculosis cases and their health programs and services, contacts. The clinic allows and supporting community- Indigenous people living in rural driven, culturally appropriate Alberta to be managed for their and culturally safe care for First TB on site rather than having Nations, Inuit and Métis peoples to travel long distances for across Canada. treatment.

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