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TABLE OF CONTENTS Chapter 5: Enhancing RQHR’s Capacity ...... 69 Infant Mortality ...... 70 Breast Feeding ...... 72 Acknowledgements ...... ii Hospital Admissions Of First Nations And Métis Infants And Children ...... 72 Executive Summary ...... iii Continuity Of Care For First Nations And Métis Newborns And Their Families...... 73 Chapter 1: Introduction ...... 1 Healthy Infant And Child Development ...... 74 About The “Working Together Towards Food Security ...... 74 Excellence (WTTE) Project” ...... 1 Teen Pregnancy And Sexuality ...... 75 Accomplishments of the WTTE Project ...... 5 Diabetes ...... 76 The RQHR’s Focus On Aboriginal Health & Dental Health ...... 77 Healing Services ...... 7 Home Care ...... 77 A Vision For The Future ...... 13 Mental Health And Addictions Services ...... 79 The Context Of This Planning Exercise ...... 14 First Nations And Métis Elders, Cultures And Conclusion ...... 16 Spirituality...... 81 Chapter 2: Best Practices ...... 19 Education, Employment And Training ...... 83 Centres Of Excellence ...... 19 The Need For Better Planning And Coordination ...... 85 Aboriginal Health and Healing Best Practices ...... 23 Budget Summary And Next Steps ...... 88 The Community Development Approach ...... 30 Conclusion ...... 90 Discussion ...... 33
Chapter 3: Partnership Opportunities ...... 37 Appendices can be found on the The Opportunities For Partnership ...... 37 RQHR web site: www.reginahealth.sk.ca Appendix A External Advisory Committee Obstacles To Moving Forward ...... 39 Members The Challenge ...... 46 Appendix B Centres Of Excellence: Best Conclusion ...... 48 Practices Appendix C Aboriginal Health and Healing Chapter 4: Towards Collaboration ...... 51 Best Practices Starting With Common Values Appendix D Strategic Options: Background and Objectives ...... 51 Paper A Conceptual Framework For Collaboration ... 54 Appendix E Partnership and Funding Opportunities: Background Paper Who Should Be Involved? ...... 58 Appendix F Aboriginal People in RQHR: How Will The Partners Work Together? ...... 61 Demographic Profile What Issues Will The Collaboration Appendix G RQHR: Profile Address? ...... 62 Appendix H Analysis Of Internal Consultation Resources ...... 63 Meetings Appendix I Key Provincial and Regional Implementing The Collaboration Framework... 64 Planning Documents Conclusion ...... 67 Appendix J Analysis Of External Consultation Meetings
Executive Summary i
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ACKNOWLEDGEMENTS People are gathering in the morning. It is a new day. From diverse walks of life and the four directions, many people are shown coming together to a common meeting place. A circle of stones reminiscent of an The project team would like to express their ancient medicine wheel marks this good meeting place. appreciation to the many individuals and organizations whose important contributions made this project The Flying Eagle, the Fire, the Trees, the Hill, The possible. These contributions came in many forms. Path and the Lake Beyond are all familiar elements of Many individuals and organizations supplied us with the Saskatchewan landscape; and they are meaningful needed information, many participated in our symbols within the region’s First Nations and Métis consultations, many provided advice and feedback on peoples cultures and consciousness. our working papers and reports, and many provided encouragement. In this graphic, our readers see many different things. Trying to explain each symbol would be a lengthy and We would particularly like to express our appreciation perhaps limiting endeavor. In the spirit of Working for the advice and support of many Elders and cultural Together Towards Excellence, we invite you to explore the advisors - Phillip Auger, Roy Bison, Doreen Gabriel, symbolic meanings of these elements in discussion Larry McKay, Louis Whiteman, Lorraine Yuzicapi, with others. We hope that through such discourse, Sterling Brass, to the members of the Aboriginal we may all come to better understandings of the value, Health Initiative Internal Working Group and to the strength and harmony to be found in our diverse members of the project’s External Advisory visions, beliefs, hopes, values and aspirations. Committee (Appendix A), including the co-chairs Bev Poitras and Tyronne Fisher. These individuals About the Artist remained active throughout the project and their contributions were a very important part of the work Linda Anderson is a Métis woman and mother who we were able to complete. We also wish to acknowledge grew up in a large family in Regina. the leadership and support provided throughout the project by Patrick Dumelie, Senior Vice President of Linda has worked for many years in human resources. Health Services with RQHR. Our summer intern Alex Currently she provides cultural awareness training and Keewatin was also a big help and a joy to work with. other workshops across the province.
Our fondest memories will be of the many friendships Art is very important to Linda. For her, drawing and and working relationships that were started or painting are essential forms of expression and strengthened through this work. In particular, the communication. Graphic art gives her the freedom hospitality and support shown by all those at Treaty 4 to say things that need to be said. She draws her and the File Hill’s Qu’Appelle Tribal Council made inspiration from her heritage, her life, her dreams and our work much more productive, and also much more her visits with Elders and close friends. enjoyable.
About the Cover Art
The graphic art on the cover aims to capture and communicate a sense of purpose and discovery that can be shared by people gathering in one place. The artwork honors knowledge and worldview of indigenous peoples. It also seeks to stimulate a sharing of understandings across cultures. ii Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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EXECUTIVE SUMMARY growing District Aboriginal population. As a result, a strategic planning process was initiated to identify key areas where resources could best be directed to achieve improvements in Aboriginal health. An internal This is the final report of Regina Qu’Appelle Health working group comprised of District staff, as well as Region’s (RQHR) “Working Together Towards an external advisors group drawn from Aboriginal Excellence” (WTTE) project. This project, initiated leadership and human service providers, was formed in the Spring of 2002, is part of ongoing efforts to to complete this Aboriginal Health Initiative (AHI). explore how the Region, together with key internal and external partners, can improve health and social The AHI Report - June 2000 identified a number of outcomes for First Nations and Métis peoples. priorities for service enhancement. As a result, two strategies were pursued. The first involved proceeding The completion of the WTTE project marks a with the development and implementation of specific significant turning point in the Region’s approach to service enhancements to address the AHI’s addressing First Nations and Métis health outcomes. recommendations. The second involved working more
While RQHR took the initiative in the completion of closely with other ○○○○○○○○○○○ the WTTE project, the report calls for a much more partners to address the ○○○○○ collaborative approach to future planning and action. determinants of First The completion of the First Nations and Métis governments, as well as other Nations and Métis organizations, must have the opportunity to join with health status, and to WTTE project marks a the Region, as equal partners, to address First Nations position the region as a and Métis health outcomes. leader in Aboriginal significant turning point health and healing. As a in the Region’s result, a new phase of work was initiated — approach to addressing History of the Project the “Working Together Towards Excellence” First Nations and Métis The history of the WTTE project dates back some (WTTE) project. ten years. In 1993, the former Regina Health District health outcomes held a public consultation with Aboriginal service During the past eight providers and community leaders. This consultation months, WTTE project was part of a comprehensive needs assessment team members, together with an active External prepared by the District. The recommendations from Advisory Committee, completed literature reviews and this consultation set the foundation for Aboriginal prepared numerous background papers. In addition, service development during much of the 1990’s. Many extensive consultations were carried out with health exciting initiatives emerged during this time, including: region staff, as well as with many external stakeholders. the opening of the Four Directions Community These included representatives of First Nations, Métis, Health Centre, the development of two healing centres municipal, provincial and federal governments, post- at the Pasqua and Regina General Hospitals, the secondary and other educational institutions, charities, creation of programs to promote Aboriginal and community-based organizations, particularly those employment and cultural awareness among staff active in serving First Nations and Métis people. within the District, and the initiation of an Aboriginal Following the 2002 amalgamation of the Pipestone, community development program. Regina and Touchwood Qu’Appelle health districts, the project’s scope was expanded to consider In 1998, the Board recognized there was an implications within the new RQHR. opportunity to become more effective in serving a
Executive Summary iii
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WTTE External Advisors Group
Treaty Four First Nations City of Regina
Jean Bellegarde, Director of Health Janet Schultz, Manager File Hills Qu’Appelle Tribal Council Community & Social Development Community Services Department David Goldsmith, Health Project Consultant File Hills Qu’Appelle Tribal Council Audra Young, Constable Media Relations Métis Nation of Saskatchewan Regina Police Service
Albert Delaire, Regional Director Educational Institutions Southern Plains Region Dr. Marlene Smadu, Associate Dean Government of Canada College of Nursing University of Saskatchewan Lynda Kushnir Pekrul, Director Regina Site Health Information Planning & Evaluation First Nations & Inuit Health Branch Calvin Racette, Director Saskatchewan Region Gabriel Dumont Institute Health Canada Shelly Agecoutay, Project Coordinator Arlene Goulet, AWPI Coordinator Urban First Nations/Métis Human Resources Education Model Indian & Northern Affairs Canada Regina Board of Education
Province of Saskatchewan Bev McBeth, Advisor Native Access Program to Nursing Heather Balfour, District Management Consultant College of Nursing District Management Services University of Saskatchewan Saskatchewan Health Regina Site
Pat Peters, Service Centre Manager Jim Hopson, Director Saskatchewan Social Services Qu’Appelle Valley Schools Fort Qu’Appelle, Saskatchewan Elaine Caswell, Superintendent of Student Danyta Kennedy, Consultant Support Services Aboriginal & Northern Justice Qu’Appelle Valley Schools Initiatives Branch Saskatchewan Justice Regina Qu’Appelle Health Region
Linda Clements, Regional Manager Tyronne Fisher, Board Member Community & Operations Regina Qu’Appelle Health Region Corrections & Public Safety Bev Poitras, Board Member Joanne Hader, Health Workforce Planning Consultant Regina Qu’appelle Health Region Health Human Resources Planning Branch Saskatchewan Health Associations
Dave Hedlund, Regional Director Victoria Gubbels, Manager Saskatchewan Social Services Aboriginal Employment Development Saskatchewan Association of Health Organizations Bruce King, Manager of Intake & Resources Saskatchewan Social Services
iv Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Why Improving First Nations and Métis is more than twice as high, the rate of smoking among Health Outcomes Must be a Priority Aboriginal people is twice as high, suicide rates are more than twice as high, half of all alcohol and drug Why should attention and resources be focused on clients of the region are Aboriginal, and rates of improving health outcomes for First Nations and Métis accidents and violence are nearly four times higher. people? There are many reasons, but three stand out: Hospitalization rates of Aboriginal people are three 1) Aboriginal people in Canada experience what the times higher for respiratory diseases, complications Royal Commission on Aboriginal Peoples has termed of pregnancy, and injuries and poisonings. “an excessive burden of ill health.” Research conducted by the former Regina Health District, as Poor health outcomes for First Nations and Métis well as many others, confirms that this is also the case people are directly linked to population health in Regina and throughout the region, 2) RQHR is one determinants and, in particular, with the social and of a handful of Canadian regions with a large and economic circumstances of Aboriginal people within growing Aboriginal population, and 3) there are extensive capacities within First Nations and Métis the region. For example, First Nations and Métis communities, organizations and governments, as well people within the RQHR have substantially lower as within other partner organizations. By working incomes, education levels and employment levels, and together, there is a potential to provide regional, they more often live in overcrowded, sub-standard provincial, national and even international leadership housing as compared to the general population. in improving Aboriginal health outcomes. However, real progress will require a workable plan, adequate At the same time that evidence of inequitable health resources, the participation and support of many outcomes has been mounting, important changes have organizations. been occurring in the demography of Aboriginal people within the region and across Canada. According According to the Royal Commission on Aboriginal to the 1996 census, some 14% of Canada’s Aboriginal Peoples (1996), life expectancy at birth for registered people live in Saskatchewan — about 75,000 First Indians in Canada is 7-8 years lower than for Canadians Nations people, about 36,000 Métis, and a small generally, infant mortality, largely a measure of socio- number of Inuit. About 4% of all the Aboriginal economic development, is twice as high, the incidence people in Canada live within the boundaries of RQHR. of chronic and degenerative diseases (cancer, heart, liver and lung disease, diabetes, etc.), previously More Aboriginal people live in the RQHR (some uncommon in Aboriginal communities, is rising, rates 33,000), than in Toronto (16,000), or Vancouver of injury, violence and self-destructive behaviour are (31,000). There are 17 reserves and a number of Métis much higher, and suicide rates among Aboriginal youth communities within the region, more than in any other are four to six times higher than the national average. Saskatchewan health region. In addition, a steadily growing number of Aboriginal people, now estimated Research carried out by the former Regina Health at some 15,000, reside in Regina. Except for Saskatoon, District confirms that there are many inequities in Regina has the highest percentage of Aboriginal people health outcomes for Aboriginal residents of Regina, of any major urban centre in Canada. as well as for those living throughout the region. Rates of teenage pregnancy are nearly four times higher, The amalgamation of the Pipestone, Regina and Aboriginal people have twice the rate of diabetes, and Touchwood-Qu’Appelle health districts has infectious and parasitic diseases, including tuberculosis, dramatically changed the Aboriginal demographic are much higher. Aboriginal people have lower rates profile of the new RQHR. Whereas only two reserves of screening (e.g. for cervical cancer), and don’t as were within the boundaries of the former Regina often participate in prevention and promotion Health District, as mentioned, there are now 17 programs (e.g., immunization), the infant mortality rate reserves within the new region. These communities
Executive Summary v
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have a total on-reserve and off-reserve population of 4. That the “determinants of health,” and particularly over 24,729, a 135% increase over the numbers within social and economic conditions, should be the former Regina Health District. When Métis are addressed because they have an important also considered, the total Aboriginal population of the influence on health outcomes; Region is estimated to be 33,000 some 33% of Saskatchewan’s Aboriginal population. 5. That best practices should be employed to build First Nations and Métis human resources, research, Changes in health district organization and and service delivery capacity, because striving for responsibilities are exciting. For the RQHR, it means excellence is important to improve health there are many new Aboriginal communities, outcomes; governments and organizations that can bring their multifaceted strengths and capacities to the challenges 6. That much more can be achieved by working faced by the region. Drawing on these strengths and together than if the partners work on their own; capacities can help ensure that all the residents of the and region have the opportunity to maintain and improve their health. 7. That by focusing on the development of new partnerships, the significant strengths and capacities RQHR is committed to achieving equitable health of First Nations and Métis peoples, as well as other outcomes for First Nations and Métis people. The organizations, can be drawn on to improve services, challenges are significant, but so are the consequences address inequities in health outcomes, and achieve of inaction. By working together with key partners, excellence. RQHR believes that there is an opportunity to have a significant impact. By focusing on the development of new partnerships, health determinants can be addressed, services can be improved and inequities in Best Practices health outcomes can be reduced. In order to inform the strategic planning process, two Together with key partners, RQHR has developed a background “best practices” papers were vision for the future. This vision recognizes: commissioned, one analyzing the best practices associated with “centres of excellence,” and a second 1. That First Nations and Métis people are entitled analyzing the best practices of leading Aboriginal to fair, equitable and just health and social health and healing programs in Canada. outcomes that are at least comparable to those of other groups in society; A key element of success that recurs over and over again, both in the formal literature and in conversations 2. That First Nations and Métis families, communities with experts in the field, points to the importance of and nations should be supported in their efforts to community involvement, community voice and a restore their strength and vitality, because this is community development approach to prevention, the foundation for health and healing; promotion and service development. Therefore, a review of some of the successes that have been 3. That more effective systems of culturally achieved by adhering to community development appropriate services should be developed and principles was also undertaken. implemented to help First Nations and Métis people restore, maintain and improve their health The analysis reveals that the best practices associated and well-being; with developing and operating centres of excellence include: a) having a clear focus and objectives (i.e. not vi Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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trying to be all things to all people), b) having objectives The best practices that were more uniquely found that, whatever their larger significance, are grounded among leading Aboriginal health and healing programs and relevant to the local community, c) having a focus included: a) an organizational focus on achieving on excellence (high standards, aspiring to be the best, equitable outcomes for Aboriginal people, b) adopting etc.), d) building on current strengths and adopting an an underlying concept of health that is holistic, c) incremental approach to development, e) achieving rooting programs in culture, d) using program and synergies among teaching, research and service organizational strategies that recognize the importance activities, f) attracting and retaining top notch talent, of building cooperation and partnerships, and d) giving
g) developing diverse the community voice in every aspect of program ○○○○○○○○○○○
○○○○○ partnerships and development and operations. Successful health and relationships to further the mission of the Experience to date clearly indicates that successful healing programs grow centre, h) ensuring health and healing programs grow out of community organizational capacity development initiatives that are pursued using out of community is up to the task, and i) community development principles. Aboriginal providing for communities are leaders in such strategies, and they development initiatives evaluation, feedback have clearly demonstrated that however well intended that are pursued using and accountability to programs may be, they will have a limited impact unless diverse constituents. communities themselves have had an opportunity to community development Programs with these identify and assess problems and participate in features distinguish searching solutions. While much can be done to principles themselves as leading support communities that are interested in going centres of excellence. through this type of process, there can be little progress if attempted solutions are externally imposed. For the RQHR and its partners, the concept of excellence was embraced, but not as an end in itself. Taken together, these best practices constitute a Excellence was seen as a goal to be achieved over time, framework within which the RQHR and its partners as partners worked more effectively together. The can develop successful Aboriginal health and healing results would include better services and better initiatives for the region. outcomes. Yet, stakeholders felt any recognition of their efforts by others should be considered a welcome by-product of the collaboration, not as an explicit goal to be pursued in its own right. Partnerships: Opportunities and Obstacles A number of best practices of Aboriginal health and From the outset of the WTTE project, the RQHR healing programs were also identified. These included recognized that it is only one organization, among best practices that might well apply to other types of many, that must continue to work together to achieve health and healing programs, as well as those that were significant improvements in health and social unique to Aboriginal programs. More generic best outcomes for First Nations and Métis people. practices included: a) being a learning organization, Therefore, one of the explicit objectives of the WTTE b) focusing on program effectiveness, c) providing for project was to engage other potential stakeholders in continuity of services, d) being client-centered, e) discussions about closer working relationships, joint making appropriate provisions for facilities, staffing priority setting and joint action. and organizational support, and f) having appropriate administrative and governance infrastructures. An extensive analysis of funding and partnership opportunities and challenges was carried out. This
Executive Summary vii
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analysis revealed that there are many organizations development principles, and the collection of insights who could become significant partners with the RQHR from both the internal and external consultations, two in improving health outcomes for Aboriginal people. strategic directions are proposed. These strategic They include, for example, First Nations and Métis directions identify how the RQHR and its partners governments, a number of municipal, provincial and can best go about addressing the need for meaningful federal government agencies, school boards, post- improvements in First Nations and Métis health secondary institutions, charities, community outcomes. organizations, and many others. However, a number of significant challenges that have proved to be The first strategy outlines a framework for joint obstacles to cooperative action in the past were also planning, joint decision making and joint action with identified. key organizations that share concerns about First Nations and Métis health outcomes (see Collaboration In working with provincial, federal and Aboriginal Framework graphic facing page). The proposal to governments, the RQHR will need to have a practical establish a “collaborative framework” reflects the fact and workable approach to address current that Aboriginal health outcomes largely result from jurisdictional realities. This must social, economic, cultural and other
involve a strategy that offers more “determinants of health” over which ○○○○○○ flexibility than past provincial and ○○○○○○○○○○○○ any one organization has quite federal approaches that have tended to Collaboration among limited control. draw hard and inflexible distinctions on questions related to jurisdiction and organizations, including Thus, collaboration among funding eligibility. Secondly, the RQHR organizations, including First First Nations, Métis, will have to take steps, in cooperation Nations, Métis, municipal, provincial with other stakeholders, to ensure that municipal, provincial and and federal governments, is essential the human resource implications of if meaningful progress is to be made. regional health and healing strategies federal governments is It is recommended that the RQHR are fully assessed and addressed. This and a number of other “core must involve an appropriate plan of essential if meaningful partners,” including First Nations and Métis governments, take a lead action to support current Aboriginal progress is to be made staff of the region. It must also involve role in establishing such a framework. significantly increasing the number of Extensive developmental work has Aboriginal staff, while enhancing already been completed on the framework. This work cultural awareness and sensitivity of all staff of the has involved the RQHR and other “core partners.” region. RQHR should deal with these issues head on, Through consultations and workshops, quite specific so as to avoid being sidetracked by these challenges ideas have evolved about the purpose of the down the road. framework, how it would operate, who would be involved, what issues it would address, and how it would be resourced.
A Framework For Collaboration The emerging consensus about how the collaboration framework would work is reflected in answers to the Building on the extensive reviews and consultations following questions: completed by the WTTE Project Team, including the review of best practices, the analysis of partnership I. What Is The Partners’ Mission? Why Do opportunities, the assessment of major obstacles, the The Partners Want To Work Together? track record of projects based on community The partners want to help ensure that First Nations viii Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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“Working Together Towards Excellence” Collaboration Framework
Serving all Residents of RQHR & Southern Saskatchewan . . .
Environment
Interdependent Autonomous Collaboration Determinants of Health Partnerships & Social Outcomes Shared Vision Joint Strategy & Values Obectives & Action Aboriginal Health Strength in Diversity Research Information, NATION PERSON Leverage Knowledge & Mental Affirm Emerging Challenges Strengths & Application & Opportunities Minimize Traditional Physical Spiritual Weakness Health Education, and Healing Emotional Excellence in Economic Conditions Employment, Health Care COMMUNITY FAMILY & Political Trends HR Build & Services Development System Develop Changes in Capacity Community Social Policy Develop Seek Funding Innovative & & Support Integrated Services
. . . With Emphasis on First Nations and Métis Citizens
and Métis people attain fair, equitable and just health because the partners believe that they will help First and social outcomes that are at least comparable to Nations and Métis people restore, maintain and those of other groups in society. improve their health and well-being;
II. What Do The Partners Consider To Be The The partners want to address the “determinants of Key Strategies That Must Be Pursued To health,” and particularly social and economic Achieve The Mission? conditions, because the partners believe that they have an important influence on health outcomes; The partners want to support First Nations and Métis families, communities and nations in their efforts to The partners want to strive for excellence in service restore their strength and vitality, because the partners delivery, because the partners believe this is the best believe these are the foundations for health and healing; way to achieve positive outcomes;
The partners want to develop and implement more The partners want to build First Nations and Métis effective systems of culturally appropriate services, human resources, research, and service delivery
Executive Summary ix
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capacity, because the partners believe this is the best The partners believe diversity is a source of strength, way to achieve excellence; a common gift to be honored, celebrated, and relied upon for the benefit of all; The partners want to employ best practices whenever possible, because the partners believe best-practices The partners believe in community involvement and insure the most effective use of available resources; inclusiveness. We want to seek ways to meaningfully involve citizens as individuals, families, communities The partners want to work together because the and nations in the development of services that partners believe much more can be achieved than by encompass prevention, care, treatment, and support working alone. for whole health; The partners believe in being innovative, creative, III. What Will Guide The Partners As We Travel flexible, productive and effective; Together Along the Path We Have Chosen? What Are Our Shared Beliefs and Values? The partners believe that partnerships are based on trust and respect, that they are fluid, dynamic and The partners believe in the Creator and that the Creator evolving, that they are mutually supportive, and that is the source of our strength and inspiration; they must be nurtured and renewed over time;
The partners believe that we have a common purpose The partners believe that every member of the and that we can make a difference; collaboration is an equal partner, and that it is both possible and desirable to share power and leadership The partners believe that mutual respect for each other amongst diverse partners; and for the jurisdictional responsibilities and autonomy of our organizations is a foundation for our work The partners believe we can work together by together; consensus, while resolving differences through open, honest and respectful dialogue; The partners believe that health is a right of every family, community, and nation, and that we must take The partners believe that effective partnerships require responsibility for our own health, while also helping a commitment from each partner that is commensurate others; with the resources, knowledge and skills of that partner; The partners believe that health is about much more than illness, disability or disease. The partners believe The partners believe that every member of the in the importance of First Nations and Métis partnership must be committed to its success, and that understandings of holistic health — that health has we will all have to put forward our best efforts to make physical, emotional, mental and spiritual dimensions; the partnership work;
The partners believe in the importance of traditional The partners believe that we can take charge of our First Nations and Métis healing knowledge and cultural future if we take joint responsibility and joint practices; ownership for the decisions that the partners arrive at together; The partners believe Western, First Nations and Métis health and healing traditions can draw on inherent The partners believe in following up our commitments strengths and compliment one another; with action;
The partners believe we can learn from and support The partners believe in being accountable to the one another and build on the strengths of each partner. community and to those the partners serve;
x Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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The partners believe that success fosters success, and • There is potential to achieve excellence by creating that our successes together must be recognized and new knowledge, improving services, and celebrated. developing Aboriginal human resources capacity;
IV. What Do The Partners Hope To Achieve By • Dealing with the issue successfully will help to build Working Together In This Way? the partnership; Priority issues that meet these criteria might include: Our relationships with one another and our partnership will strengthen; • Addressing poverty, unemployment and other determinants of health; First Nations and Métis health and social outcomes will improve; • Addressing the need for Aboriginal human resources development; First Nations and Métis peoples will make an increasingly important contribution to Saskatchewan’s • Developing support services for children, youth prosperity and well-being; and families at risk;
Resources will be used more effectively; • Developing public awareness and support services for health promotion, illness prevention, and The partners will be recognized by those we serve as positive personal health practices; having provided leadership; and • Incorporating culture and spirituality into program Our partnership will be an example and a source of development and service delivery across sectors; inspiration to others. • Identifying and prioritizing significant service gaps; The collaboration framework partners would be and selective in the issues they address. Criteria used to identify suitable issues for consideration include: • Improving coordination among various agencies, communities and levels of government. • The issue has the potential to significantly impact First Nations and Métis health outcomes; The collaboration framework will require support to perform a number of specific functions. These include: • The issue crosses mandates and responsibilities of a number of sectors and partners, it does not fit 1. The planning, coordination and evaluation of neatly into the responsibilities of one or more First Nations and Métis health services, including, existing partners; for example: developing annual plans, goals, and • The results are achievable in a reasonable time expected outcomes, preparing proposals for new frame; services, evaluating existing services, preparing annual reports and other reviews that describe • The issue is identified by partners and the services and the outcomes being attained; community as significant; 2. Providing support to managers within the • There is potential to develop innovative solutions; RQHR and other partner organizations in their strategic and operational planning. This might • There are opportunities to realign existing include participating in strategic planning initiatives, resources, access new resources, or create synergies evaluation initiatives, accreditation reviews, service among the partners; quality audits, etc.;
Executive Summary xi
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3. Maintaining current and complete information 9. Providing a secretariat-type function to the about programs and services related to Aboriginal Collaboration Framework, Advisory and Elders health, and making this information available to groups, and other working groups that are managers, boards, the public, and interested established by the partnership. This would insure stakeholders. This would include raising awareness the development and implementation of within and outside the partner organizations about appropriate action plans, coordination of efforts, commitments and accomplishments related to First and timely reporting to member organizations; Nations and Métis health, for example, making presentations to internal and external groups, 10. Representing the partners in a wide variety of attending key conferences, and maintaining on- external forums where First Nations and Métis going communication with key Aboriginal and non- health and social issues are being addressed; and Aboriginal government representatives. 11. Generally serving as a point of information, referral, contact, communication and support 4. Liaison and coordination with external for Aboriginal health issues within the region. stakeholders. This would include networking with government and non-government representatives, In order to implement the collaboration framework, representatives from other levels of government additional steps to build on the emerging consensus (municipal, federal, provincial), and representatives will be required. Specifically, it will be necessary to from other organizations (e.g., universities) who secure commitments from the “core partners” and are not core members of the collaboration to get this new decision making and planning forum framework; up and running effectively.
5. Serving as a high profile point of first contact While the challenges are significant, so are the for internal and external stakeholders on a wide opportunities. By working together in a new, more variety of issues related to First Nations and Métis collaborative way, the partners believe that much more health. This would involve networking, dialoguing can be accomplished than if they continue to work in and maintaining on-going communication with relative isolation on many common issues of concern. these and other key groups; The concept is to pool talents, strengths and even resources. Such an approach holds the promise of 6. Developing joint projects and strategies with inter-sectoral action on key priorities that would be internal and external stakeholders to promote difficult or impossible for any one organization to address. collaboration and improve health outcomes. Current information about funding opportunities would be maintained and assistance in developing proposals and strategies would be provided; Primary Health Care Services 7. Providing analysis and advice to senior management and the Boards of partner While the Collaboration Framework is being organizations with respect to Aboriginal health developed, and even after it begins to address the broad policy and service issues; and complex social and economic issues that influence health outcomes, there will continue to be a need for 8. Enabling the core partners and other partners all human service organizations, including the RQHR, to improve the cultural appropriateness, quality and to examine how the cultural appropriateness, quality effectiveness of services by removing barriers, and effectiveness of services can be improved. The accessing new resources, and linking organizations second recommended strategic direction addresses together so that they can better draw on each other these issues. strengths and capacities; xii Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Based on the continuing work of the Aboriginal Health to these initiatives, there is also a need to improve Initiative Internal Working Group, a number of home care services, mental health and addictions opportunities to improve RQHR’s health services for services, culture and spirituality programs, and the First Nations and Métis people have been identified. region’s education, employment and training In addition to these service improvements, there is a programming in support of First Nations and Métis need to increase the RQHR’s capacity to plan and health initiatives. coordinate its First Nations and Métis health initiatives. This second strategic direction, therefore, focuses on While many needs and opportunities have been how the RQHR should go about significantly identified by various internal and external stakeholders, enhancing its organizational capacity to address First those mentioned above require priority attention for Nations and Métis health issues. several reasons. These are the areas where the most serious inequities exist for Aboriginal people. They The Aboriginal Health Initiative, an extensive, two year are also the areas where there are opportunities to research, planning and consultation process initiated prevent serious health problems down the road. by the former Regina Health District, identified a Furthermore, a good deal of information is already number of priority areas for improving health services available about effective health promotion strategies for First Nations and Métis people. During the course in these areas and, therefore, there is the very real
of the WTTE project, there was an prospect of having a significant impact
○○○○○○○○○ opportunity to confirm the ○○○○○○○○○ over a reasonable time frame. importance of these priorities and to develop specific ideas about the best Health promotion program Several common themes run through strategies for addressing current gaps the specific program enhancements and needs. In addition, the Aboriginal improvements should that are proposed. The initiatives involve: a) working together in new Health Initiative Internal Working focus on infant and child Group has continued to meet. The ways with community partners, members of this Group provided development and the including First Nations and Métis leadership in the development of representatives, b) bringing together specific plans to implement the AHI’s strengthening of research, teaching and education recommendations. As a result of this components, c) increasing access to significant work, it is now possible to Aboriginal families culturally appropriate and sensitive identify a number of specific and services, d) increasing the number of complimentary recommendations for Aboriginal staff, e) enhancing training the consideration of senior and professional development management and the Regina Qu’Appelle Regional opportunities for existing Aboriginal and non- Health Authority (RQRHA). Aboriginal staff of the region, f) increasing research activities to access critical information for future Extensive research and consultations indicates that planning purposes, and g) better integrating, there are a number of opportunities for the RQHR to coordinating, planning and evaluating Aboriginal improve health promotion programs for First Nations health initiatives across the region. and Métis infants, children and families. These efforts should focus on infant and child development and the strengthening of Aboriginal families. Specific priorities for action include: infant mortality, breast feeding, the reduction of hospital admissions of First Nations and Resource Requirements Métis children and youth, continuity of care for First While a number of proposed initiatives can be carried Nations and Métis newborns and their families, infant out with existing resources, new resources will be and child development, food security, teen pregnancy required to fully implement the strategic directions that and sexuality, diabetes, and dental health. In addition have been outlined.
Executive Summary xiii
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Financial assistance from a variety of sources could government’s Primary Health Care Transition Fund. significantly reduce these budgetary requirements. For The WTTE team, together with key RQHR senior example: staff and the partners in the Collaboration Framework, has already submitted a letter of intent and will be • A specific objective of the Collaboration developing a detailed submission to the Primary Health Framework is to re-align existing resources so that Care Transition Fund requesting $2m in funding over they are more supportive of agreed upon priorities. three years. Other organizations will have access to funds that could be used to support the priorities that have The receipt of funds from these sources could been identified; significantly reduce the budgetary implications for the RQHR. For the time being, however, these • The creation of a new position responsible for First Nations and Métis health services planning and WTTE Budget Summary coordination has been proposed. One of the important 2003-2004 2004-2005 2005-2006 responsibilities of this position will a. Collaboration Framework $ 200,000 $ 350,000 $ 450,000 be to assist the RQHR and its b. Primary Health Services $ 775,500 $ 1,049,000 $1,002,000 partners to access additional funds from government and other sources. The analysis conducted by RQHR Total $ 977,500 $ 1,399,000 $1,452,000 the WTTE team indicates that there are many significant funding Partners $ 105,000 $ 545,000 $ 650,000 opportunities that are not currently being pursued. There is Total $ 1,082,500 $ 1,944,000 $2,102,000 every reason to believe that a dedicated effort to tap into these resources will implications have not been considered, since funding meet with considerable success; is required now to demonstrate RQHR’s commitment and to get the ball rolling. • RQHR continues to dialogue with the provincial government about increased support for Aboriginal health services, both through the Primary Health Care Transition Fund and from other sources. This is a high priority with Implementation Saskatchewan Health, and RQHR is well positioned to work with the provincial government Before proceeding with implementation, the WTTE and other partners to play a leadership role in the project team completed a further round of province; and consultations with both internal and external stakeholders. At the time initial consultations were • If the federal and provincial governments act on done, input was sought on a number of broad issues the recommendations of the Romanow concerning the state of Aboriginal people’s health and Commission, additional funding will become how the RQHR and its partners could best go about available for services in rural and remote areas. The improving health outcomes. As a result of these early Commission has recommended that some of these consultations, much more specific ideas and proposals funds be specifically earmarked for improved have been developed. Therefore, the project findings Aboriginal health services. and recommendations were taken back to those who were involved at an earlier stage. The findings and The most promising opportunity is the federal recommendations were presented, input was sought, xiv Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ and adjustments were made to the plans and unprecedented opportunity to build on considerable recommendations. expertise and important working relationships to develop more effective strategies for working together. Final recommendations were taken forward to the RQHR’s senior management and the RQRHA. It is Despite past commitments and initiatives, significant recommended that the RQHR’s senior management disparities in Aboriginal health and social outcomes and the RQRHA approve the WTTE initiatives and remain. The RQHR and its partners recognize that associated budgets for implementation beginning in existing services and systems do not always work well 2003-2004. While RQHR decisions are being and, sometimes, they fail Aboriginal people completely. confirmed, other partners in the Collaboration Therefore, as important as past initiatives have been Framework will also have an opportunity to consult to the health and well-being of Aboriginal residents within their own organizations. of the RQHR, real progress will require that many organizations increase their participation and support, Current planning processes within the RQHR, and work more closely together. including the work of the Aboriginal Health Initiative Internal Working Group, will continue The WTTE partners have a vision during this time. The development and ○○○○○○○○○○○○○○○○○○○○ of many organizations working implementation of various Aboriginal Real progress will require together to address the primary health care initiatives, determinants of health. By including the preparation of a funding that many organizations pursuing a collaborative approach, proposal for the federal government the RQHR and its partners have will also continue. increase their participation the opportunity to provide leadership in an area of critical and support, and work more There will also be a continuing role for importance to the region. This the WTTE team. Follow-up activities closely together leadership can go a long way in will include disseminating the report insuring that new and already findings, incorporating suggested available resources are used in changes, supporting the RQHR in the ways that have the most beneficial establishment of the Collaboration Framework, impact on the health of First Nations and Métis coordinating Aboriginal primary health care initiatives peoples. across the region, and working on the funding proposal for the Primary Health Care Transition Fund. It is time to implement changes to longstanding service delivery practices and models that have been far too segmented, and far too focused on illness, not health. The foundation for a new approach is the recognition that important contributions must be made by many Conclusion organizations. Organizations must be brought together to develop joint plans and implement joint action. The RQHR and its partners in the WTTE initiative Considerable progress towards this goal has already believe that lower Aboriginal health outcomes in the been achieved. The region is well positioned to take RQHR are unacceptable. For this reason, over the last advantage of current opportunities and, by doing so, decade, a number of prevention, community will continue to build on a reputation as a leader in development and direct service programs to address Aboriginal health and healing services. Aboriginal health needs have been developed. At the same time, Aboriginal governments and organizations have been developing a broad range of community- based, holistic health, justice, social services and child welfare programs. As a result, there is now an
Executive Summary xv
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xvi Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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CHAPTER 1 Chapter 2: Best Practices - provides a summary of two background papers prepared for the project. These discuss the best practices associated with centres of excellence, and with leading Aboriginal Introduction health and healing programs in Canada;
Chapter 3: Opportunities For Partnership - identifies the various stakeholders who are in a position to partner with the RQHR to improve This is the final report of Regina Qu’Appelle Health health services for First Nations and Métis peoples; Region’s (RQHR) “Working Together Towards Excellence” (WTTE) project. This project, initiated Chapter 4: Towards Collaboration - discusses how in the Spring of 2002, was part of ongoing efforts by the RQHR and its partners might go about the Region to explore how, together with key internal establishing an ongoing mechanism for joint and external partners, health and social outcomes for planning and decision making related to First First Nations and Métis peoples could be improved. Nations ands Métis health issues; and
The completion of the WTTE project marks a Chapter 5: Enhancing RQHR’s Organizational significant turning point in the Region’s approach to Capacity - discusses some of the initiatives that Aboriginal health issues. Ongoing work to improve RQHR should undertake immediately to improve health outcomes will be required, and an ambitious First Nations and Métis health outcomes. plan of action is proposed. However, a different way of working together with other partners is also A number of the key background reports prepared outlined. While RQHR has been a catalyst in the by the Project Team are available on the RQHR completion of the WTTE project, and while the website at www.rqhealth.ca. Other reference material Region will have to take the lead on a number of may be obtained from the Project Manager. internal initiatives, the report recommends that future planning and action increasingly rely on a much more collaborative approach. About the “Working Together Towards First Nations and Métis governments, as well as other Excellence” Project organizations, must have the opportunity to join with the Region, as equal partners, to work towards the The “Working Together Towards Excellence Project” common objective of improving health outcomes. was the most recent in a series of initiatives in the Therefore, a new partnership is proposed. As this area of Aboriginal health undertaken by RQHR. partnership forms and begins to work, health However, the history of the project dates back some outcomes for First Nations and Métis people will ten years. improve. In turn, social and economic goals of the region and the province will be advanced. In 1993, a public consultation was held by the former Regina Health District with Aboriginal service This report is organized into five chapters: providers and community leaders as part of a comprehensive needs assessment. The Chapter 1: Introduction - provides an overview of recommendations from this consultation set the the planning process, the reasons why it was foundation for Aboriginal service development during undertaken, and the context within which it was much of the 1990’s. Many exciting initiatives in the completed; area of Aboriginal health emerged during this time,
Chapter 1: Introduction 1
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including the opening of the Four Directions Com- process. This report also identifies target areas and munity Health Centre, the development of two heal- recommendations for District action. ing centres at the Pasqua and Regina General Hospi- tals, and the creation of staff positions to address rep- The Aboriginal Health Initiative identified seven resentative workforce development and Aboriginal strategic principles to be applied to future planning in community development. the area of Aboriginal health: These are:
In 1998, the Regina District Health Board recognized 1. Services will treat the whole person, acknowledging
a need to be more the interconnection of spiritual, emotional, mental
○○○○○○○○○○○ ○○○○○ strategic in identifying and physical health within the individual and the initiatives that could importance of family and community to the health The AHI project effectively serve a and well being of Aboriginal people; underscored the growing District Aboriginal population. 2. Services will recognize and affirm the cultural necessity of considering As a result, District identity of Aboriginal people; staff were requested to Aboriginal health and undertake a strategic 3. Services will be geographically and culturally planning process to accessible to Aboriginal people; social outcomes from a identify key areas where broader, more holistic resources could best be 4. Aboriginal citizens and agencies will be involved directed to achieve in program planning and implementation; perspective improvements in Aboriginal health. An 5. Aboriginal people will be given a voice in decision internal working group making and opportunities to participate in comprised of District processes that foster health; staff, as well as an external reference group made up of Aboriginal citizens and a broad cross-section of 6. Efforts will be made to establish relations and human service providers, was formed to undertake partnerships with First Nations and Métis the initiative. governments that foster mutual support and cooperation for health improvement; and The Aboriginal Health Initiative (AHI) undertook a comprehensive review of Aboriginal health needs and 7. Multi-sector collaboration and cooperation will be service gaps in Regina, and identified a number of a part of future action for Aboriginal health. priorities for service enhancement. Recommendations from the AHI project were reviewed by senior In addition to identifying specific health needs and management and the District Board, and a number service gaps, the AHI project underscored the of initiatives were approved for implementation necessity of considering Aboriginal health and social beginning in 2002. outcomes from a broader, more holistic perspective, one that would take account of the determinants of Two reports were produced by the AHI project: an health. In this regard, the AHI confirmed the results Aboriginal Profile (Regina Health District 2000), which of many previous studies that have consistently found provides data on the demographic and socio-economic that the most significant health and social inequities characteristics of the Aboriginal population in Regina, can be directly linked to inequalities in income, and an Aboriginal Health Initiative Report (Regina Health education, employment, and access to quality child District 2001), which summarizes the information care and housing. Moreover, the AHI project gathered through an extensive community consultation determined that many existing services are not
2 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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culturally appropriate and that there is an urgent need effectiveness of the District would require a focus on to build health and healing capacity within Aboriginal achieving excellence in one or more key areas that communities themselves. would both build on core competencies, and address the most pressing health priorities of the community. The AHI assisted the District in identifying a number Consensus was quickly reached that the area of of priorities for service enhancement. The project also Aboriginal health and healing should be a top priority. made clear that significant improvements in the health status of Aboriginal residents within the District could Two directives came from the Regina District Health only be achieved through a broader, multi-sectoral Board to the District Management Team. The first approach to collaboration, one which would involve was to proceed with the development and many stakeholders. In particular, a coordinated action implementation of action strategies to address the plan was seen to be required. First Nations and Métis recommendations from the Aboriginal Health governments and organizations, Initiative. The second was to take
federal, provincial and municipal steps that would position the region ○○○○○○○○○○ governments, the education and ○○○○○○○○ as a leader in Aboriginal health and employment sectors, labour, New challenges and healing. In response to these professional associations, community directives, the AHI Internal Working groups, and charitable organizations opportunities have added Group was expanded to include were all felt to be essential those responsible for developing and further impetus to the participants in the development of a implementing new Aboriginal health joint action plan. former District’s initiatives, and a new phase of the project was initiated to engage key Thus, the recommendations from the determination to explore a external partners. This new phase Aboriginal Health Initiative were of was called the “Working Together bold new initiative in two kinds; some identified the need Towards Excellence” (WTTE) for enhancements and changes to the Aboriginal health and project. current health care delivery system, while others were of a more sweeping healing Another significant development nature, setting the direction to work that has shaped the WTTE project across sectors to affect health occurred early in 2002. As discussed determinants. Addressing the latter recommendations more fully below, the Saskatchewan government was seen to be necessary to achieve real change in the announced a significant reconfiguration of health health status of Aboriginal people within the region. districts. A smaller number of much larger regional Their implementation would require a fundamentally health authorities have now been created and have different approach to planning and service delivery. begun operations. In the case of Regina, three health districts were combined. Because of these changes, The evolving perspectives and determination within the number of First Nations and Métis residents within the former Regina Health District coincided with an the region has increased substantially. Within the extensive strategic planning process undertaken by the expanded boundaries of the new Region, there is now District Board and senior management. During this a significant number of First Nations people who process, the District clarified its vision, mission, values reside on reserves, as well as much larger urban and and goals.1 A key result of this process was a rural/off-reserve Aboriginal populations. determination that improving the long-term In the brief time since the reorganization of health districts, there have already been many opportunities 1. The RQHR is actively engaged in developing mission, vision and for the RQHR to work with other partners across value statements for the new Region.
Chapter 1: Introduction 3
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4 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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consultations, the preparation of reports, and the In addition, the project’s External Advisory Committee development of recommendations. The Project also played a key role in identifying opportunities and Team also reviewed and refined the project working challenges for this analysis. papers and final report; and
6. Consultant Reporting to the Project Sponsor, John Hylton’s Accomplishments of the WTTE Project role was to acts as a resource to the Project Team by providing leadership in developing and carrying In addition to various background documents setting out project work plans, developing the strategic out the vision, objectives and work plan for the plan, and preparing the background and final “Working Together” project, a number of reports and written reports. discussion papers were developed. These documents are available to all interested stakeholders, at website The collection of information for developing the www.rqhealth.ca and they constitute an important RQHR’s strategic plan was completed over the legacy of the project. These documents include: Summer, Fall and Winter of 2002, and entailed the following: • Aboriginal Profile Prepared as part of the AHI project in 2000, this 1. A review of the literature pertaining to Aboriginal document provides a comprehensive demographic health issues and “centres of excellence”; profile of Aboriginal residents residing within the former Regina Health District. In addition to 2. A review of relevant government and non- analyzing demographic trends, the report compiles government documents relating to Aboriginal available information with respect to the use of policy, Aboriginal health, and Aboriginal various health services by Aboriginal people (e.g., community initiatives; immunization rates, hospitalization admission and discharge statistics, morbidity and mortality data, 3. Extensive internal consultations with key staff etc.); within the RQHR. These consultations brought together small groups of key staff from across the • Aboriginal Health Initiative Report Region; This is the final report of the AHI project. Completed in 2001, it outlines a number of 4. Extensive and on-going consultations with principles and values that should guide the numerous external stakeholders, including First development of improved health services for Nations and Métis government and non- Aboriginal residents. It also identifies a number of government organizations, as well as priorities for improving the organization and representatives of municipal, provincial and federal delivery of services. Priorities identified in the government departments. These meetings involved review include: 1) working across sectors to address representatives from other organizations whose the determinants of health, 2) developing improved involvement in collaborative action on Aboriginal services in infant and child development, mental health and social conditions was considered health, addictions, pre-natal care, and health essential; and promotion, 3) affirming the importance of indigenous knowledge, traditional healing and the 5. Several special consultations involving community involvement of elders, and 4) working to strengthen representatives, First Nations and Métis Aboriginal families and to build Aboriginal governments, Elders, and community-based community capacity; organizations.
Chapter 1: Introduction 5
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• Updated Demographic Profile • “Working Together:” An Analysis of Feed- This report updates the information in the Aborigi- back from the External Consultation Sessions nal Profile to take account of the new, expanded Throughout the WTTE RQHR. While not a comprehensive review, the project, extensive consultations were held with a report does provide available data with respect to variety of First Nations, Métis, government and the number and location of Aboriginal residents community stakeholders. This report provides de- and communities. The report identifies the Indian tails of the consultations, as well as a summary of reserves within the Region, and the on-reserve and the main themes that emerged; and off-reserve populations of each; • Strategic Options for Improving Aboriginal • Planning Environment: Environmental Scan Health and Healing Services This paper identifies and analyzes a number of key This discussion paper sets out a number of broad factors in the former Regina Health District and strategic options for the consideration of RQHR provincial planning environments that must be and its potential partners in an Aboriginal health considered in developing plans for Aboriginal and healing initiative. The main focus of the report health and healing; is to present broad strategic options and to discuss how each option might be implemented. • Aboriginal Health and Healing: A Review of Best Practices In addition to the above noted reports, there have been This discussion paper identifies a number of a number of other significant developments since the leading Aboriginal health and healing programs in “Working Together” project was initiated: Canada, and discusses some of the best practices that contribute to their success; • As already mentioned, many RQHR staff have had an opportunity to participate in consultations on • Centres Of Excellence: A Review of Best the project. The Aboriginal Health Initiative Practices Working Group also received regular briefings and This discussion paper reviews the development, provided ongoing input and direction to the project; operations and accomplishments of leading centres of excellence in Canada. The best practices that • The RQRHA, the Senior Management Team and contribute to their success are identified and the Medical Advisory Committee were briefed on discussed; the project and provided input;
• “Working Together:” An Analysis of • An information session involving some forty Feedback From the Internal Consultation representatives from a wide variety of external Sessions stakeholder groups was held on May 13th at the During May 2002, the project staff for the Four Directions Community Health Centre; “Working Together” project conducted a series of intensive workshops with a broad cross-section of • An External Advisory Committee made up of key RQHR senior staff, management staff, and front- stakeholders external to RQHR, including First line workers. These consultation sessions were Nations and Métis government and community designed to illicit feedback on the strengths, representatives, was formed in June 2002, and it weaknesses, opportunities and threats that should continues to meet regularly with region staff. This shape the Region’s Aboriginal health and healing committee is co-chaired by two Aboriginal initiative. This report summarizes and analyzes the members of the new RQRHA; feedback received during these workshops; • An information session for interested community
6 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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groups, particularly those involved in the delivery Considerable momentum has been built up as a of health and social services to Aboriginal residents consequence of the WTTE project, and the of the region, was organized on August 27th. This consultations described above are expected to continue resulted in important feedback being provided to on after the completion of the project. the project team;
• Meetings were held with a number of First Nations and Métis government leaders, and communication is ongoing; RQHR’s Focus on Aboriginal Health and Healing Services • Since June, a number of meetings have been organized with external stakeholder organizations. Why should the new RQHR focus its attention and Among others, these organizations have included resources on improving health outcomes for First provincial, federal and municipal governments, Nations and Métis people? There are many reasons, some education sector partners (universities, but three stand out: 1) Aboriginal people in Canada SIAST, etc.), and health charities. The purpose of experience what the Royal Commission on Aboriginal these meetings was to explore the Peoples has termed “an excessive
perspectives and priorities of these ○○○○○○○○○○○○○○○○○○ burden of ill health.” Research organizations, as well as to explore conducted by the former Regina common ground for moving for- Aboriginal people in Health District, as well as many others, ward to improve Aboriginal health confirms that this is also the case in Canada experience what outcomes; Regina and throughout the Region, 2) the Royal Commission on RQHR is one of a handful of Canadian • Meetings were also initiated with regions with a large and growing key national research, policy and Aboriginal Peoples has Aboriginal population, and 3) as funding organizations including, for previously mentioned, there are example, Indian and Northern termed “an excessive extensive capacities within First Affairs Canada, Health Canada, Nations and Métis communities, burden of ill health” Justice Canada, Solicitor General organizations and governments, as well Canada, the Correctional Service of as within other partner organizations. Canada, the Office of the Federal By working together, there is a Interlocutor for Métis and Non-Status Indians, the potential to provide regional, provincial, national and Canadian Institutes for Health Research, the even international leadership in improving Aboriginal National Aboriginal Healing Organization, and the health outcomes. However, real progress will require Aboriginal Healing Foundation; a workable plan, adequate resources, and the participation and support of many organizations. • A consultation session with representatives of the former Pipestone and Touchwood Qu’Appelle Aboriginal Health Conditions Health Districts, the Regina Health District’s partners in RQHR, occurred in May. According to the Royal Commission on Aboriginal Communication is ongoing; and Peoples (1996), Aboriginal health and social conditions in Canada reflect “an excessive burden of ill health.” • Comprehensive bibliographies on topics relevant In particular, the Commission noted that: to the WTTE project have been prepared. In addition, nearly one hundred key documents have been identified, obtained and indexed. These are • Life expectancy at birth is 7-8 years less for being placed in the Region’s library for ongoing registered Indians than for Canadians generally; reference and research purposes.
Chapter 1: Introduction 7
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• Infant mortality, largely a measure of socio- physician contacts for 100 people within the former economic development, is twice as high for District, but 17.3 contacts for registered Indians; registered Indians as for other Canadians; • 86% of 100 new tuberculosis cases in the former • Most infectious diseases are more common among Regina Health District in 1997 were Aboriginal, Aboriginal people; and more than half of these were under 20 years of age; • The incidence of chronic and degenerative diseases (cancer, heart, liver and lung disease, diabetes, etc.), • The infant mortality rate was 8.4 (per 1000 live previously uncommon in Aboriginal communities, births) within the former RHD, but 19.3 for is rising; registered Indians within the District;
• Rates of injury, violence and self-destructive • 61% of First Nations adults over 15 smoked within behaviour are disturbingly high. One third of the the former District (vs. 31% in the general deaths of registered Indians are due to accidents population); and violence; and • Half of the alcohol and drug clients within the • Suicide among Aboriginal youth is four to six times former District were Aboriginal; higher than the national average. • There were 12 suicides per 100,000 population each The former Regina Health District’s Aboriginal Profile year within the former District, but 25 for registered report (Regina Health District 2001) also found many Indians in Saskatchewan; inequities in health outcomes, both in Regina and throughout the region. In particular, the analysis found: • There were 31 deaths from motor vehicle accidents per 10,000 registered Indians in Saskatchewan, and • With regard to teen pregnancy, within the general 8 per 10,000 for Saskatchewan as a whole; population, there were 30 live births per 1000 women in the 15 to 19 age range, but 115 for • Rates of homicide and intentional injuring were registered Indians within the former Regina Health six times higher among registered Indians; and District; • Aboriginal people within the former District • Registered Indians have substantially lower experienced much higher rates of hospitalization incomes, education levels and employment levels, (298% higher for respiratory diseases — colds, flu, and more often live in overcrowded, sub-standard asthma, tuberculosis – 309% higher for housing; complications of pregnancy, childbirth and puerperium, 328% higher for conditions in the • Aboriginal people have lower rates of screening perinatal period, and 279% higher for injuries and (e.g. for cervical cancer), and don’t participate as poisonings). often in prevention and promotion programs (e.g., immunization); The analyses completed by the former District indicated that poorer health outcomes are directly • 7% of the First Nations population within the linked with population health determinants and, in former District (vs. 3.4% in Saskatchewan) have particular, with the social and economic circumstances diabetes; of the Aboriginal people who lived within its boundaries. • Infectious and parasitic diseases result in 3.7
8 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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For example: people within the Regina Health District, 7% of the district’s population. This constituted 13.5% of the • 50% of Aboriginal residents had completed high provincial Aboriginal population. Of these Aboriginal school, vs 66% for the general population; residents, two-thirds were estimated to be First Nations, while one-third was estimated to be Métis. • Employment stood at 42% for Aboriginal residents, At the time, the analysis indicated that 94% of the but 65% for the general population; District’s Aboriginal population lived in Regina (Regina Health District 2001). • Average income in 1995 was $25,820 vs. $14,584 for Aboriginal residents. The amalgamation of the Pipestone, Regina and Touchwood-Qu’Appelle Health Districts has These findings clearly point out the complexity of dramatically changed the Aboriginal demographic needs, service gaps, challenges and opportunities that profile of the new RQHR. Whereas only two reserves face the RQHR and its partners. were within the boundaries of the former Regina Health District, there are now 17 reserves within the A Large and Growing Aboriginal Population2 new region, the largest number within any health region in Saskatchewan (see Figure 1.1 and
Figure 1.2). These communities have ○○○○○○○○○○○○○○
According to the 1996 census, some ○○○○○ 14% of Canada’s Aboriginal people a total on-reserve and off-reserve While the general population live in Saskatchewan — about population of 24,729. (see Table 1.1). 75,000 First Nations people, about in Saskatchewan is not 36,000 Métis, and a small number As a result, some 33% of of Inuit. Some 33% of growing, and is aging, the Saskatchewan’s First Nations Saskatchewan’s Aboriginal population (now estimated to be some population (about 4% of all the Aboriginal population is 85,000 to 90,000 people), live within Aboriginal people in Canada) live the boundaries of the new region. younger and growing much within the boundaries of RQHR. Whereas Health Authority # 9 (Prince Albert-Parkland) has a slightly larger more quickly More Aboriginal people live in on-reserve population, the off-reserve RQHR (some 33,000), than in population of bands within RQHR Toronto (16,000), or Vancouver (16,269) is by far the largest of any (31,000). There are 17 reserves, three tribal councils region, some 50% higher than the region with the next and a number of Métis communities within the Region, largest number. more than in any other Saskatchewan health region. In addition, a steadily growing number of Aboriginal If there is one third as many Métis as First Nations people, now estimated at some 15,000, reside in people within the boundaries of the new health region Regina. Except for Saskatoon, Regina has the highest (a ratio that often seems to hold true in these types of percentage of Aboriginal people of any major urban analyses, but an assumption that needs to be confirmed centre in Canada. with further study), it may be estimated, that some 8,160 Métis also now live within the boundaries of Prior to the formation of the RQHR, it was estimated the new region. This would bring the total Aboriginal that there were approximately 14,000 Aboriginal population within the region to some 33,000, a 135% increase over the Aboriginal population within the
2. This analysis varies somewhat from the original background paper “ Preliminary Demographic Analysis of First Nations and 3. These figures also assume that the off-reserve population Métis People” that was circulated in 2002. The earlier analysis did resides within the region, or that any proportion that does not is not include the Sakimay First Nation. The appended version matched by off-reserve members of bands from outside the includes the Sakimay First Nation. boundaries of the region who now live within the RQHR.
Chapter 1: Introduction 9
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Figure 1.1 Regina Qu’ Appelle Health Region
10 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Chapter 1: Introduction 11
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Table 1 First Nations On-Reserve and Off-Reserve Populations 2001: RQHR
On-reserve Off-reserve Total Yorkton Tribal Council 71. Ochapowace First Nation 566 732 1,298 72. Kahkewistahaw First Nation 445 909 1,354 73. Cowessess First Nation 537 2,544 3,081 74. Sakimay First Nation 246 1,029 1,275 1,794 5,214 7,008
File Hills Qu’ Appelle Tribal Council 76. Carry the Kettle First Nation 764 1,280 2,044 75. Piapot First Nation 626 1,192 1,818 80. Muscowpetung First Nation 308 754 1,062 81. Peepeekisis First Nation 660 1,472 2,132 82. Okanese First Nation 252 272 524 83. Starblanket First Nation 233 269 502 84. Little Black Bear First Nation 219 201 420 78. Standing Buffalo First Nation 398 608 1,006 79. Pasqua First Nation 561 965 1,526 4,021 7,013 11,034
Touchwood Agency Tribal Council 85. Muskowekwan First Nation 382 918 1,300 87. Day Star First Nation 136 275 411 86. Gordon First Nation 1,028 1,590 2,618 88. Kawacatoose First Nation 1,099 1,259 2,358 2,645 4,042 6,687
Total 8,460 16,269 24,729
Source: Registered Indian Population, 2001 - Indian & Northern Affairs Canada (obtained from: www.ainc-inac.gc.ca)
increase of 41% and a rural decrease of 16%. Be- the mid nineties was 7.1%. Given this trend, the tween 1967 and 1992, the off-reserve First Nations current percentage is almost certainly much higher. population in Saskatchewan increased by 86% (Federation of Saskatchewan Indian Nations 1997). In Saskatchewan, one quarter of all labour force At the same time, the on-reserve population of First entrants, and one third of all new school entrants, are Nations people is also growing. This population Aboriginal people. Over the next ten years, the increased by 514 between 1998 and 2001 – about 6.5% Aboriginal labour force is expected to grow by 280% over a five year period. from 82,000 to 311,000, while the non-Aboriginal labour force is expected to grow by only 7.5% from The proportion of the urban population that is made 665,000 to 685,000.4 up of Aboriginal people is also growing. In Regina, Census data indicates that 2% of the city’s population 4. Federation Of Saskatchewan Indian Nations (1997). Saskatch- was Aboriginal in 1971. The figure was 4% in 1981, ewan and Aboriginal Peoples in the 21st century. Regina: PrintWest and 5.8% in 1991. The estimate based on data from Publishing Services.
12 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Experience and Commitment A Vision for the Future Despite many initiatives over the past decade, The RQHR believes lower Aboriginal health outcomes significant disparities in Aboriginal health and social in the Region are unacceptable. For this reason, over outcomes remain within the Region. It is widely the last decade, as previously mentioned, RQHR has recognized that existing services and systems do not implemented a number of prevention, community always work well and, sometimes, they fail Aboriginal development and service programs to address people completely. Therefore, as important as past Aboriginal health needs. These include, for example: initiatives have been to the health and well-being of the establishment of Aboriginal healing centres within Aboriginal residents of the Region, real progress will large, acute care hospitals, the development of the Four require much greater participation and the support Directions Community Health Centre in North Central of many other organizations. Regina, the hiring of an Aboriginal community development coordinator, the establishment of a Through discussions and consultations, it has become representative workforce program, and the clear that RQHR, First Nations and Métis introduction or expansion of numerous well-baby, governments, and many other organizations share a family support, mental health, diabetes, addictions and common vision: other programs. As a result of this commitment, RQHR has developed considerable expertise, an 1. Aboriginal people should have health and social extensive pool of experienced and dedicated staff, and outcomes that are similar to those for other a wide network of important working relationships. residents of the Region; All of these are significant assets in addressing health outcomes for Aboriginal people. 2. Health and wellbeing of First Nations and Métis people must be restored and maintained through Together with its partners, RQHR believes that the effective, culturally appropriate programs and Region can become nationally and internationally services; recognized as a centre of excellence for Aboriginal health and healing, by demonstrating: 1) how the health 3. The Region and its partners have an opportunity and wellbeing of First Nations and Métis people can to move to a position of national leadership in be restored and maintained through effective, culturally Aboriginal health and healing; appropriate primary health care programs and services, 2) how better coordination involving health, justice, 4. RQHR is one partner, among many, that must be education and social services can be achieved, 3) how involved in working together to improve outcomes; services in urban, rural and reserve communities can and be better coordinated, and 4) how culture and community form the base for the development of 5. The strength and vitality of Aboriginal families, health and healing strategies. communities and nations are the foundations for more effective health and healing strategies. At the same time, throughout the course of the project, conventional ideas about “centres of excellence” were Thus, the primary purpose of the WTTE project has continually challenged. As discussed more fully in the been to explore partnership opportunities with First next chapter, there were several problems with the Nations, Métis and other stakeholders, to identify and notion of a “centre of excellence.” Thus, midway build upon the strengths that exist within the current through the project, to reflect an evolution in thinking, stakeholder environment, and to develop a concrete, the project was renamed from the “Aboriginal Health joint plan to achieve excellence in Aboriginal health and Healing Centre of Excellence Project” to “The and healing services, teaching and research – based Working Together Towards Excellence Project.” on best practices.
Chapter 1: Introduction 13
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The Context of this Planning Exercise organizations have been developed to strengthen working relationships and accelerate the pace of The development of RQHR’s Strategic Plan occurs change; at a time when there is significant interest and activity in the area of Aboriginal health within the province • A number of Aboriginal organizations in and across Canada. Saskatchewan, including both First Nations and Métis governments, have amassed considerable The Saskatchewan Context experience in developing effective health programs for their members. In many instances these For many years, First Nations and Métis health issues programs have attracted national and even have also been a matter of concern for health system international attention; planners and provincial Aboriginal organizations in Saskatchewan. As a result, the WTTE project is being • Through the efforts of the Saskatchewan Indian conducted within a provincial context where the need Federated College, the Gabriel Dumont Institute, to improve health outcomes for Aboriginal people is and many other First Nations and Métis post- already well recognized. For example: secondary education programs, there has been a dramatic increase in the number of First Nations • Throughout the years, the provincial government and Métis people who possess the professional has commissioned many reports examining the qualifications needed to pursue health careers; extent and causes of poor Aboriginal health outcomes; • Improving health status for First Nations and Métis peoples is now listed as a core strategy in the • During the last two decades in particular, a number strategic plans of most significant health care of specialized programs have been developed both organizations in Saskatchewan; and provincially and locally to improve the quality and effectiveness of health services provided to • Both the Métis Nation of Saskatchewan and the Aboriginal people. There has also been some Federation of Saskatchewan Indian Nations have creative use of alternative approaches to providing identified health issues as priorities, both have health services to Aboriginal people, particularly assigned ministers to a health portfolio, and both in the North; have developed strategic plans and/or position papers outlining current problems and future • Starting in the 1970s, serious efforts were begun directions. to provide cross-cultural awareness training to staff working in health services and to hire more From a provincial perspective, the Fyke Commission Aboriginal staff. These efforts have intensified in Report, the Action Plan for Saskatchewan Health Care, recent years. and the provincial plan for the development of primary health care services are the most important and current More recently, there have been a number of important planning documents that set the strategic framework developments in Saskatchewan: for the work of RQHR. There are many dimensions to the government’s Action Plan, including primary • A number of health regions, including RQHR, have health care services, emergency services, and completed special reviews addressing Aboriginal recruitment challenges. The plan also speaks to the health issues; need to promote healthy communities by bringing together partnerships involving regional health • Framework agreements among health districts, authorities, the business community, health groups, governments and Aboriginal governments and and the human and social services sectors to develop
14 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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a provincial “Population Health Promotion Strategy.” • Many provincial and federal government Fundamental to the plan is the government’s decision departments involved in health services now have to restructure health care in the province to create 12 staff or entire departments that specialize in new regional health authorities from 32 existing Aboriginal health issues; districts. As mentioned previously, RQHR is an amalgamation of the Pipestone, Regina and • Programs to improve health services for First Touchwood Qu’Appelle Health Districts. Nations and Métis people (e.g., Aboriginal Head Start programs) have become an integral part of In addition to the reorganization to health authorities, the health system in most parts of the country; the Action Plan identifies three priorities in relation to Aboriginal Health: 1) to work in partnership with • The literature in the field has become so the federal government and First Nations and Métis voluminous, that a number of bibliographies and people in order to expand primary health services in reviews have appeared in recent years. For example, Aboriginal communities, 2) to work in partnership with the Royal Commission commissioned a the Colleges of Nursing and Medicine and other health comprehensive review of Aboriginal health disciplines to give greater priority to Aboriginal health commissions and research projects from Carleton issues, and 3) to encourage greater Aboriginal University that identified hundreds of reports; participation in the workplace. • Numerous conferences, special intergovernmental The provincial government’s Action Plan clearly projects, and federal-provincial meetings have been acknowledges the need to focus on Aboriginal health organized to deal with Aboriginal health issues; issues through the formation of strategic partnerships to improve health outcomes. Partly for this reason, • Health services are a priority with all First Nations, the directions being taken by the WTTEP have been Métis and Inuit governments, with the national strongly supported by Saskatchewan Health. Aboriginal organizations, and with many other Aboriginal government and non-government The National Context organizations throughout the country. Sometimes with the assistance of federal and provincial governments, these organizations have prepared Although concerns about the health status of First briefs, completed needs analyses, developed plans, Nations and Métis date back many years, throughout and implemented numerous programs to improve Canada interest has surged during the 1980s and 1990s. access to services, provide specialized Aboriginal For example: services, and improve health and social outcomes for Aboriginal people; • Many provinces have completed major inquiries focusing on Aboriginal health issues; • As will be discussed more fully in Chapter 2, there are also quite a number of current initiatives and • The Royal Commission on Aboriginal Peoples funding opportunities being promoted by several produced a special “round table” report on federal government agencies; and Aboriginal health issues, and the Commission devoted an entire volume of its final report to • Most recently, the Romanow Commission report Aboriginal health and social policy; has underscored the urgency of developing new ways to fund, plan and deliver health services for • Prominent organizations, including the Canadian Aboriginal people. Medical Association, as well as many other professional organizations, have produced special As a result of these various initiatives, it is now reports on Aboriginal health; generally recognized among those involved in
Chapter 1: Introduction 15
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Aboriginal health services that: 1) Aboriginal people there is often little or no coordination of the ser- have much poorer health outcomes compared to other vices for Aboriginal people between the urban ar- Canadians, 2) Aboriginal people often do not feel well eas and rural, home communities; served by the Canadian health system, 3) mainstream service providers often experience considerable • In most parts of the health system, serious prob- frustration in attempting to extend culturally lems remain in attracting and retaining Aboriginal appropriate and effective services to Aboriginal staff; peoples and communities, 4) the health system often fails Aboriginal people in important ways, and 5) • First Nations and Métis organizations and govern- Aboriginal people want to become much more directly ments are anxious to move forward with improved involved in designing and delivering holistic health programs in many areas, and they have expressed services based on traditional beliefs and practices. frustration and impatience about what they per- ceive to be the slow pace of change; The Challenges Ahead • Although there has been much discussion, there Although there has been considerable activity in recent remains no agreement about the exact form that years, serious challenges remain. Although it is beyond Aboriginal health programs should take in the scope of this report to provide a detailed analysis Saskatchewan; of all these challenges, several are identified here by way of providing a context for the discussion that • Progress is further complicated by a continuing lack follows: of agreement among governments about their respective jurisdictional responsibilities. • There is continuing evidence that Aboriginal people Thus, while there is strong interest in the area of suffer what the Royal Commission has referred to Aboriginal health services on the part of many key as an “excess burden of ill-health”. While this is stakeholders in Saskatchewan and nation wide, and true in relation to infectious diseases, it is also the while there has been a marked increase in commitment case in relation to many chronic conditions, such and level of activity over the past few years, a number as diabetes and heart disease; of significant obstacles remain. It is within this context that there is an opportunity for the RQHR to take the • As the AHI Report has clearly indicated, the most initiative in establishing a partnership that draws on disproportionate “burden of ill health” is related the capacities and strengths of many organizations. to a whole host of socio-health, family and Further planning and action can occur collaboratively, community problems, including mental health and knowing that proposed priorities and approaches are addictions concerns, that are a by-product of supported by key stakeholders including federal, inadequate social conditions, including poverty, provincial, First Nations and Métis governments. unemployment, low educational attainment, poor housing, and insufficient access to social supports;
• There is a shift in demand on health services from reserves and Northern communities to urban areas. Conclusion This reflects broader migration trends of First Nations and Métis peoples. At present, the There is a large and growing population of Aboriginal infrastructure does not exist in urban centres to people within Saskatchewan and within the boundaries provide the range of health services, particularly of RQHR. The importance of this population to the culturally appropriate health services, that are makeup of the provincial population is increasing needed for First Nations and Métis peoples, and rapidly. This population is much younger than the
16 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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general provincial population. As a consequence, Aboriginal people are making an ever increasing contribution to the well-being of the province.
Some 33,000 Aboriginal people live within the boundaries of RQHR. This is a 135%increase over the numbers within the previous Regina Health District. RQHR has more Aboriginal communities than any other health region in Saskatchewan. Moreover, whereas the Aboriginal residents of the former Regina Health District overwhelmingly resided in urban areas, the urban-rural split within the new health region is closer to 50%-50%.
There are very serious inequities in health and social outcomes for Aboriginal people. While there is some indication that some of these gaps are getting smaller, very significant challenges remain. This is particularly the case with regard to education and employment status, income differentials, the large number of single parent families, and the impact of these social conditions on health outcomes.
RQHR is committed to achieving equitable health outcomes for First Nations and Métis people. The challenges are significant, but so are the consequences of inaction. By working together with key partners, RQHR believes that there is an opportunity to have a significant impact. By focusing on the development of new partnerships that draw on the significant strengths and capacities of First Nations and Métis peoples, as well as other organizations, services can be improved, inequities in health outcomes can be addressed, and excellence can be achieved.
Chapter 1: Introduction 17
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18 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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CHAPTER 2 The “Core Functions”of Centres of Excellence Five distinct functions of centres of excellence may Best Practices be identified.1 These include: • Identification of Knowledge Requirements Identifying what knowledge is important;
• Acquisition of Existing Knowledge In order to inform the RQHR’s strategic planning Acquiring existing knowledge through, for process, two background “best practices” papers were example, establishing resource centres, developing commissioned, one dealing with the best practices relationships with experts in the field, convening associated with “centres of excellence,” and a second conferences, commissioning reviews of existing addressing the best practices of leading Aboriginal research, etc.; health and healing programs in Canada. This chapter • summarizes the findings of these two reports. Creation of New Knowledge Carrying out research to fill important gaps in A key element of success that recurs over and over knowledge; again, both in the formal literature and in conversations • with those who have been involved, points to the Assimilation of Knowledge importance of community involvement, community Using knowledge to improve policies, programs, voice and a community development approach to products and services through staff training, development. Therefore, a third section of this chapter advocacy, teaching students and practitioners, etc.; describes this approach and some of the successes and that have been achieved by adhering to community • Dissemination of Knowledge development principles. Disseminating knowledge through educational In the final section, a number of the key findings from activities, the preparation of publications, public the foregoing analysis are brought forward. It is education, etc. suggested that these findings provide important These can be said to be the “core functions” of centres guidance for the RQHR and its partners, because they of excellence. point to the ingredients that have contributed to successful collaborations in other settings. Particularly in the area of Aboriginal health and healing services, it is important to recognize that knowledge comes about not only as a result of research and training conducted within a Western paradigm. Centres of Excellence Indigenous knowledge is also vitally important. This is the knowledge that comes about as a result of Centres of excellence offer products and services of experience and as a result of the transmission of superior quality. To do this, they become “knowledge culturally appropriate knowledge through oral management enterprises.” To achieve excellence, no traditions, apprenticeships, and ceremonies. Indeed, matter what products or services are provided, these one of the most significant challenges for Aboriginal enterprises carry out a number of important and inter- health and healing centres of excellence is to develop related “knowledge” functions.
1. These functions are mentioned here. A more detailed discussion will be found in the background paper appended to this report.
Chapter 2: Best Practices 19
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appropriate strategies to combine Western and Centres of excellence maintain a wide network of Indigenous knowledge. relationships with experts in their respective fields. Some of these relationships are initiated and How the Core Functions of Centres of maintained by individual staff members at the centres, Excellence are Carried Out but others are built into the organizational structure of the centres themselves, for example, through While there is no one accepted template for carrying advisory committees, review committees, governance out the core functions of centres of excellence, an structures, etc. These networks often extend to other examination of the practices of such centres reveals experts throughout the country and, indeed, that there is remarkable similarity in the types of throughout the world. activities that they routinely carry out. To acquire existing knowledge, centres of excellence: To identify knowledge requirements, centres of 1) acquire key journals and publications, 2) maintain excellence employ leaders in their respective fields. libraries and resources centres, 3) commission reviews These individuals, by virtue of their training and of the state of knowledge in their respective fields, 4) experience, have extensive knowledge about what is invite leaders to come to the centres to provide teaching and training, 5) sponsor mentorships, staff known in a particular field and about the key obstacles exchanges and advanced training for staff at leading to achieving improvements in efficiency or centres of excellence, 6) promote participation at effectiveness. important national and international conferences, and 7) sponsor their own publications and conferences and Centres of excellence usually employ teams of invite leading experts in the field to participate. individuals with related specializations. These individuals interact frequently to share existing Increasingly, centres of excellence rely on advanced
knowledge and to discuss technology for these knowledge acquisition and ○○○○○○ ○○○○○○○○○ gaps in knowledge. sharing activities. These include, for example, internet To create new list servers, on-line chat rooms, on-line publications, Centres of excellence the use of telehealth technology, etc. knowledge, centres of conduct reviews of the state of knowledge. These To create new knowledge, centres of excellence excellence maintain reviews identify what is maintain active research programs. These programs known in a particular field, help to insure that researchers and practitioners are active research as well as the important up to date on the existing state of knowledge, and programs questions that have not yet that they are actively engaged in addressing the key been resolved. outstanding questions in their respective fields.
Staff from centres of Research activities vary widely in scope and tend to excellence subscribe to the leading publications and rely on diverse funding sources. Very little research is attend the leading conferences in their respective fields. carried out solely with the centres’ internal budget, although a modest budget for start up and other This insures their knowledge of the field is current. purposes is often provided. More typically, research is Many centres of excellence produce their own carried out in collaboration with others from other centres or from associated industries, universities or publications and convene their own conferences in public sector agencies. Funding is typically provided order to be at the centre of knowledge generation and from diverse sources such as government, industry, knowledge dissemination in their fields of expertise. foundations, and the charitable sector. Many health These commitments allows such centres to remain centres of excellence conduct their own fundraising current about the state of play in particular fields. activities to generate public support for their research and services.
20 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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To assimilate knowledge, centres of excellence tend funding. This is particularly true of federal and to rely heavily on internal programs of staff training provincial governments. For example, federal support and staff development, but they also encourage their for research programs in centres of excellence may staff to participate in outside conferences and training come from the Canadian Institutes of Health opportunities. Key staff publish frequently and the Research, the Canada Foundation for Innovation,
centres themselves often maintain their own publishing Genome Canada, the ○○○○○
programs. Increasingly, information is dispersed within Canada Research ○○○○○○○○○○○○○ these organizations through the use of advanced Chairs program, the To disseminate technology. Canadian Health Services Research knowledge, centres of Where centres of excellence are involved in service Foundation, the delivery, considerable attention is usually also paid to Canadian Institute excellence engage in a the development of best practices and bench marks. for Health These organizations commit themselves to high information, the number of activities. standards and continuous quality improvement. They Network of Centres These include lobbying, are constantly involved in monitoring, reviewing and of Excellence evaluating the efficiency and effectiveness of their program, and any public education, and practices. They want to insure that existing knowledge number of other is being used appropriately. In addition, where sources. Similarly, professional training and improved approaches are demonstrated through provincial funding research, they want to insure this new knowledge is may be channeled development disseminated within their own institutions and beyond. through the Health Ministry, the provincial agency responsible for health To disseminate knowledge, centres of excellence research, universities, or line departments with engage in a number of activities. These include responsibility for water quality, environmental lobbying, public education, and professional training protection, workplace safety, social services, justice, and development. women’s issues, or any number of other sectors.
Other Features of “Centres of Excellence” With respect to governance, there are two common models. In one model, the centre of excellence is In addition to the activities related to the core functions separately incorporated. It maintains its own corporate of the centres of excellence, there are several other structure, including financial administration, by-laws, common features that have to do with funding, etc. Relationships with sponsoring organizations are governance, evaluation, accountability, public relations, the subject of written agreements and, sometimes, by- and recruitment. laws etc. These generally insure that the sponsoring organizations have a role in the governance of the With regard to funding, centres of excellence rely on centre (e.g., seats on the board, etc.). Notwithstanding very diverse funding sources to carry out their service the legal independence of some centres, they may still and research programs. In the case of centres within rely on host or sponsoring institutions for a variety of the health field, most would receive some funding support services, from space to human resources, from: 1) their host institutions, 2) federal, provincial equipment, and financial administration. and local governments, 3) leading national health charities (Cancer, Heart and Stroke, Diabetes, etc.), 4) A second model sees centres of excellence established foundations, 5) funding bodies in other countries as programs within host institutions, such as health (particularly the National Institutes of Health in the authorities or hospitals. In some instances, there is a U.S.), and 6) international health organizations (e.g., direct reporting line to a university or hospital the World Health Organization). Moreover, within administrator, but many centres have also established each funding type, there may be multiple sources of advisory boards of various types.
Chapter 2: Best Practices 21
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There is no “preferred” governance model. Each inform, to invite input, to explore new partnerships, model is appropriate to certain circumstances. and to strengthen community, professional and political support for the activities of the centres. With regard to evaluation, where formal evaluations of centres of excellence have been conducted (e.g., With regard to recruitment, expert practitioners and ARA Consulting Group 1997), the criteria typically researchers are attracted to organizations where considered include: excellence is a priority and where there is institutional support for research and teaching. Leading • The excellence of the centres research program; practitioners and researchers like to work beside other successful practitioners and researchers. Thus • The success of the program in attracting and attracting and retaining leading professionals requires retaining highly qualified personnel; a coordinated approach that combines the development of an institutional culture that rewards • The success of the program in education, training, research, teaching and innovation, with the and professional capacity building; establishment of core groups of experts in related fields that can create a stimulating professional • The strength and effectiveness of the networks and environment. Where these elements can be brought partnerships that have been
together, the result is usually the best developed by the centres; ○○○○○○○○○○○○○○○○○ researchers, teachers and practitioners • The extent to which the centres have There is no “preferred” working with the best students, fostered multi-disciplinary, multi- providing services of superior quality, governance model, sectoral and integrated service and in an environment where collaborating organizations and funding sources research programs that, but for the each model is centres, probably would not have provide significant support. been developed; and appropriate to certain How Centres of Excellence • The extent to which the management circumstances Develop and organization of the centres have Centres of excellence do not develop contributed to their success. from a single decision at a single point With regard to public relations and accountability, in time, nor are they produced by a grant from a centres of excellence view their constituencies in very funding body. Rather, they tend to develop over time, broad terms, and they make extensive and on-going although spurts in growth certainly occur. Generally, efforts to connect with their constituencies in a variety a core group of experts and expertise is established. of ways. While centres feel a sense of responsibility Sometimes a number of these core groups come to sponsoring and collaborating institutions, they also together. A vision is developed, and synergies are see themselves as being accountable to the professional found among various groups and institutions. Existing community, the research community, and the public. programs and resources are adapted to address the In addition to annual reports, therefore, most centres common vision, and new opportunities to grow and have developed newsletters and periodic updates develop are fully exploited. Trust, credibility and designed for the broader professional community and capacity develop over time. the public. Many centres also sponsor public events Centres of excellence are typically rooted in local to report to the community on activities. Centre communities where individuals and organizations administrators typically devote a good deal of time to form “clusters” to advance their common interests. meeting with government and community leaders. While the stereotypical “cluster” is located in a large Through these reports and meetings, centres seek to urban area (e.g., high tech in Ottawa, aerospace in
22 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Montreal, etc.) this is by no means exclusively the case. procedures to address standards in the following areas: Many smaller communities also have significant knowledge and entrepreneurial resources, but they may 1. Being a Learning Organization lack the networks, infrastructure, investment capital These standards cover the topics of planning or shared vision to live up to their full potential. In services for the population served, using evidence these instances, it is all the more important that and cultural approaches, and striving for quality community leaders mobilize stakeholders – business, improvement; local governments, universities, colleges, and voluntary organizations – to develop innovative strategies that 2. Achieving Wellness harness local knowledge resources for local benefit. These standards cover the topics related to the programs of the centre, including health promotion, prevention, early detection, and health protection;
Aboriginal Health and Healing Best 3. Being Responsive Practices These standards cover the topics of continuity of In discussing Aboriginal health and healing best services, and clients’ first contacts with the practices, it is possible to distinguish between two organization. They also address how well the broad categories of best practices: 1) those that organization finds creative and innovative strategies Aboriginal health and healing programs share in for applying resources to meet stated outcomes; common with other types of health and healing 4. Addressing Needs programs, and with human services program generally, These standards cover the topics of client and 2) those that are unique to Aboriginal programs. assessment and diagnostic services;
The Common Ground 5. Empowering Clients These standards cover the topics of giving After extensive consultation with Aboriginal program information, consents, and clients’ rights, and managers, academics, and other leaders in Aboriginal address other ways that programs support clients health and healing, the Canadian Council on Health to choose good health; Services Accreditation (2000) developed comprehensive standards for First Nations and Inuit 6. Setting Goals addiction and community health services programs. These standards cover the topic of planning What is most striking about these standards, is how services for each client; similar they are to the standards that are often used in assessing non-Aboriginal programs. This result should 7. Delivering Services not be surprising. It confirms that any effective human These standards cover delivering services, services organization must attend to certain medications, and clients’ responsibilities, including prerequisites of effectiveness, for example, planning what partnerships are developed to deliver effective and assessing services, training and monitoring staff, services; and evaluating outcomes. Indeed, these areas of common ground point to some of the possible areas 8. Achieving Positive Outcomes of cooperation between Western and Aboriginal These standards cover the topic of best results; healing paradigms. and
Specifically, the Canadian Council’s accreditation 9. Maintaining Continuity guidelines suggest that Aboriginal health and healing These standards cover the topic of transition or programs should develop policies, programs and end of service.
Chapter 2: Best Practices 23
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For each standard, a number of specific criteria have crippling injuries of the past. Yet, doing so is not their been developed by CCHSA. In addition, the Council job alone. Only when the deep causes of Aboriginal has provided a comprehensive overview of possible ill health are remedied by Aboriginal and non- indicators and data sources that could be tapped to Aboriginal people working together will balance and assess performance relative to each criteria. harmony — or health and well-being — be restored.
Aboriginal Concepts of Health and Healing Western notions of health and healing have tended to emphasize the dependence of the individual receiving Because there are many common standards, some care on the care provider. However, the language, might wish to rush to the conclusion that there are no values and practices at the core of Aboriginal traditions significant differences in the best practices of emphasize personal, family and community Aboriginal and non-Aboriginal programs. However, a responsibility for health. significant body of research and experience, including research conducted by the Regina Health District, It is a strongly held belief of Aboriginal cultures that suggests that this is not at all the case. To understand human beings are profoundly interdependent and have the differences, it is helpful to review some of the their greatest potential to live in health, happiness and differences in basic understandings and beliefs about prosperity when they congregate and co-operate in what health is and how it is achieved and maintained.2 communities, large or small. “Community” is an old and honored notion in Western cultures as well, In the imagery common to many Aboriginal cultures, although it generally takes second place to “individual” good health is a state of balance and harmony as a core value. involving body, mind, emotions and spirit. It links each person to family, community and the earth in a circle According to Aboriginal tradition, the health and well- of dependence and interdependence, described by being of individuals depends in part on community some in the language of the Medicine Wheel. In non- health and social dynamics. Much of the most Aboriginal terms, health has been seen primarily as convincing recent health policy literature agrees. Both an outcome of medical care. But we are quickly sources provide evidence that some aspects of ill learning that any care system that reduces its definition health cannot be understood except in terms of social of health to the absence of disease and disability is behavior, and they cannot be alleviated except through deeply flawed (see Table 2.1). collective action. Examples range from the transmission of infectious diseases to the norms that The word “healing” is familiar to non-Aboriginal tolerate family violence. people, of course, but the idea that Aboriginal people have in mind when they use it is not the same. Healing, Aboriginal people from almost every culture believe in Aboriginal terms, refers to personal and societal that health is a matter of balance and harmony within recovery from the lasting effects of oppression and the self and with others, sustained and ordered by systemic racism experienced over generations. Many spiritual law and the bounty of Mother Earth. Aboriginal people are suffering not only from specific Aboriginal people have long understood that the well- diseases and social problems, but also from a being of people depends on the well-being of the air, depression of spirit resulting from 200 or more years water, land and other life forms. This belief has been of damage to their cultures, languages, identities and confirmed by the findings of countless scientific self-respect. The idea of healing suggests that to reach studies of poor health in compromised environments. “whole health,” Aboriginal people must confront the Although the details of cause and effect have not been fully established, the general scientific conclusion is clear: human health depends largely on the condition
2. What follows draws heavily on the seminal work of the Royal of the natural environment and of the built Commission on Aboriginal Peoples (1996). environment. Classic Aboriginal concepts of health
24 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Table 2.1 Western and Aboriginal Approaches to Health and Healing (RCAP 1996)
The Conventional Western Approach The Traditional Aboriginal Approach
Community health care Community healing and wellness
Historically grounded in infectious diseases, public Oriented to health promotion framework health models and physical illness encompassing physical, spiritual, social, emotional, etc.
Dominated by biomedical approach to illness, Based on holisitc, culturally appropriate concepts treatment and care of health
Hierarchical in structure, professional expertise as Consensual in structure, expertise indigenous to determining factor the nation and community
Segregation of program activities by discipline and/ Integration of program activities to reflect holistic or bureaucratic responsibilities perspective
Program-specific funding within narrow definiton of Block funding of programs, activity based on health jurisdiction holistic concept of health
Programs and service providers accountable to Programs and service providers funciton under authorities external to community Aboriginal jurisdiction, with accountability to the community
Health research developed externally and divorced Health research generated to respond to from community planning and self-identified needs community priorities
Health care system encourages transfer of clients Health care system encourages capacity building out of community to non-Aboriginal care systems and providing services to community members at home and healing take the view that all the elements of life and world. The circle (or wheel) embodies the and living are interdependent and, by extension, well- notion of health as harmony or balance in all being flows from balance and harmony among the aspects of one’s life . . . [Human beings] must be elements of personal and collective life (see Table in balance with [their] physical and social 2.2).3 According to RCAP (1996): environments in order to live and grow. Imbalance can threaten the conditions that enable the person The Native concept of health is said to be holistic to reach his or her full potential. because it integrates and gives equal emphasis to the physical, spiritual, mental and emotional aspects According to RCAP (1996): of the person. The circle is used to represent the A new approach to Aboriginal healing that inseparability of the individual, family, community embodies the characteristics of equity, holism, Aboriginal control and diversity, has the power to 3. This table, adapted from Malloch (1989), and the one above, are do what the present system cannot: to go beyond not intended to be unduly provocative. The intent is to highlight services to focus on whole health. It will break differences in perspective and approach. It is acknowledged that these are general statements that do not always apply. down restrictive program boundaries to focus on
Chapter 2: Best Practices 25
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Table 2.2 A Comparison of Western Medicine and Traditional Indian Medicine
Conventional Western Medicine Traditional Indian Medicine
Analytic approach - separation of body, mind and Integrated, holisitic approach to health: body, mind spirit (total split between medicine and religion) and spirit interact together to form person
Emphasis on disease, treatment Emphasis on prevention of sickness
Impersonal, “scientific” approach to health and Personal responsibility for health and sickness sickness
Health and sickness understood in terms of Health and sickness understood in terms of the quantifiable, scientific data laws of nature
Man controlling nature, manipulation natural Man living in balance with nature, with natural law variables
Western medicine governed by laws of the State, Traditional medicine governed by the laws of the amn-made laws which grow out of a political- Creator — what we need comes from Earth — economic system food, medicines, water, education, religion and laws
Doctor is accountable to the government, and to Medicine man is accountable to the Creator, to the his professional association people, to Elders of his medicine society
Medicine is a business, the patient is the Medicine is not for sale, not for profit — it is a gift consumer, the doctor and the medical industry to be shared profit
The government, the taxpayer and the consumer The land and the people support the medicine man support the doctor and the practice of medicine and his practice
Encourages dependency on professionals and the Encourages self-sufficiency, self-care, state responsibility and control by the people
healing, not just for individuals but for communities Aboriginal and non-Aboriginal health and healing and nations. It will restore a focus on aspects of concepts and programs, there are also many important well-being that are lost in the current system: child differences. We now turn to a discussion of the best and maternal health, health promotion and practices that are associated with the unique cultural education for self-care, social and emotional health, aspects of Aboriginal health and healing programs. the jurisdictional issues that block the way to health problem solving for all Aboriginal peoples. It will What Is Unique About Aboriginal Health and blend the insights of traditional and contemporary Healing Programs? Aboriginal analysis with the emerging analysis of the determinants of health. It will honour the Based on the findings from their consultations, Regina needs, values and traditions of those it serves. Health District’s Aboriginal Health Initiative (RHD 2001) identified seven strategic principles to guide the Despite the common ground that exists among development of effective service strategies for
26 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Aboriginal people. These principles, which were 1. Rooted in Culture discussed in the introduction, confirm the findings of Successful healing programs are deeply rooted in the Royal Commission on Aboriginal Peoples (1996). Aboriginal cultural traditions. Considerable effort has been made to insure that the program design In their analysis, the Royal Commission (1996) builds on values and traditions that are rooted in proposed four principles to guide reforms in the area Aboriginal culture. To achieve this focus, successful of health and social services: programs rely on elders, community leaders and staff with extensive backgrounds in and 1. Aboriginal health and healing systems should be commitment to culture. Cultural dimensions of based on holistic concepts of health and well-being healing are featured not only in the program itself, that are firmly rooted in Aboriginal traditions, but also in the training of the staff, and in the rather than on the more limited biomedical concept administration of the program. The most of health; successful programs embed and weave culture into every aspect of the program. 2. Aboriginal health and healing systems should be controlled by Aboriginal people themselves, not 2. Person-Centered imposed from the outside; Whatever the beliefs of the staff and advisors, successful healing programs recognize that there 3. Aboriginal health and healing systems should are important individual differences among clients provide services and achieve outcomes that are and that individuals must be allowed to make equitable with those available for other Canadians; choices about the types of learning and healing and that will work best for them. Rather than requiring a standardized approach, successful programs 4. Aboriginal health and healing systems must be provide opportunities and encouragement, but then founded on a respect for cultural diversity. allow individuals to make decisions about their own healing journey. The best programs are prepared In RCAP’s (1996) formulation: to adjust the program content and length to meet the specific needs of individual clients, and they The four characteristics of a new health policy — also organize specialized programs for groups of equity, holism, Aboriginal control, and diversity — clients who have common learning or healing are interdependent and mutually reinforcing. Only needs. Successful programs also make adjustments if taken together will they provide the basis for with respect to the cultural aspects of the healing. Aboriginal and non-Aboriginal people, working These programs recognize that there are individual together, to construct the transformed health and and community differences in terms of adherence healing systems that Aboriginal people have said to Aboriginal and Western culture and healing they want and that all the evidence at our disposal paradigms. says they need. 3. Commitment to Client’s Rights The Aboriginal Healing Foundation (2001) has also Successful programs are very clear about the identified a number of key ingredients of successful responsibilities of the program staff and about the healing programs. Their review determined that rights and responsibilities of the clients who choose successful healing programs, whether they are to participate in the healing program. Thus, residential or non-residential, specialized or more successful programs are voluntary. In addition, general, have a number of very important common clients receive clear information about the rules characteristics. AHF believe these common and expectations before agreeing to participate, characteristics are the basic ingredients that allow the their agreement to participate in the program is programs to be successful. These criteria include: formalized in a written acknowledgment or
Chapter 2: Best Practices 27
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contract, they receive a detailed orientation to the and community leaders. Checking out the program that allows them to fully participate, they reputation of the elder or healer in their home are told that they have rights and how they can community is a necessary step in the screening exercise them. Moreover, continuous efforts are process. In addition, feedback from clients and staff made to monitor clients’ participation in the about the performance of the Elders and healers program to insure that rights and responsibilities is continuously sought. Like others involved in the are being respected. program, Elders and healers have regular appraisals of their performance. Elders and healers participate 4. Quality Assurance Program in the healing community, including community Successful healing programs make a substantial, events, staff training exercises and the like. If there systematic and ongoing commitment to quality are any concerns about a healer or Elder, they are assurance. Client and staff feedback is continuously not invited back to participate in the program. solicited and used to improve the program, files are monitored, staff are appraised, specific 6. Staff Selection and Training initiatives are assessed, and the entire program is Successful programs have highly experienced and continuously evaluated. A genuine commitment to highly committed staff. Training may involve a continuous learning and quality improvement combination of formal education and professional results in programs that continue to grow and adapt qualifications, but the most important element is to meet the needs of clients. It is this commitment on-the-job training and experience. Successful that contributes to their success, rather than programs employ staff who have themselves whether the program adopts any particular healing struggled with healing issues, who have embarked philosophy, program structure, or therapeutic on a healing path, who have achieved success in technique. Successful new program components healing, and who regard healing as an ongoing are developed when they build on a strong base personal priority. Successful programs carefully and when they grow out of the experience and screen staff, solicit ongoing feedback from clients commitment of the staff, the board and the and other staff about performance, and conduct community. regular and comprehensive performance appraisals. Successful programs also make a significant 5. Elders commitment to ongoing staff training and team Successful healing programs make extensive use building. Furthermore, they have “staff-friendly” of Elders and traditional healers. In successful personnel policies that recognize the difficulty of programs, clients often report that the spiritual the work. In new programs, intensive staff training aspects of healing are the most beneficial. Elders is completed before any clients are accepted for and healers provide individual and group treatment. counseling and support, but they may also advise on the overall structure of the healing program. 7. Governance Elders and healers are selected not only on the basis Successful healing programs operate at arms-length of their experience as elders and healers, but also from the political structures in the community, on the basis of their counseling skills and their however, they are also closely linked to and abilities to contribute to the overall program. Elders supported by the community. Boards of respected and traditional healers may be members of the staff, community leaders with backgrounds and interests or they may operate more independently. in healing provide oversight and direction to the program. These directors also model the healing In successful programs, Elders are carefully way that the program seeks to promote. Links to screened and their ongoing participation in healing the community are a priority of directors, program is carefully monitored. Screening involves checking administrators and staff. These links insure that credentials and references with respected Elders the community understands and supports the
28 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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program, and that clients can fully avail themselves with clients before they come to the program to of the opportunities in the community. insure clients receive the maximum benefits when they come. They also follow-up clients in the Successful healing programs recognize that there community to provide on-going advice and is an opportunity and a responsibility to provide support. Before, during and after the program, healing opportunities beyond the local community. every effort is made to link clients with the With whatever resources they have available, these resources in the community that can provide programs support clients and communities within ongoing support. their provinces and regions. Where they have developed, effective regional governance structures 11. Operational Policies have evolved out of local programs and Successful programs have amassed detailed community-based governance structures. As these operational policies governing all the important local programs have gradually built and extended aspects of program operations. For residential their programs, their governance structures have programs, for example, these policies might address evolved to reflect their broadened mandates. This client and staff safety issues, admission and is a bottom-up process that adapts to changing discharge from the program, personnel issues, community and organizational needs, rather than intake and referral procedures, board operations, a top-down process that is part of a pre-conceived record keeping (including financial records and plan. client files), financial administration, and many other issues. The programs that have been most 8. Facilities Successful programs have adequate successful in developing detailed operational facilities that afford privacy and dignity to clients. policies are those that have been through a formal Successful healing programs, and the facilities that accreditation process by a recognized accrediting support them, take a holistic approach to healing authority. Because program managers, staff and that includes arts, cultural, recreational, spiritual, Board members have specifically addressed many healing and other components. “what if ” scenarios, they have forced themselves to confront difficult issues and to make informed 9. Client Selection and Screening decisions about how these issues will be resolved. Successful programs do not attempt to be “all This improves quality initially and also in the longer- things to all people.” They carefully consider the term, since the policy development experience is types of clients that will benefit most from the integrated into ongoing program, staff and board program that is being offered. There is also a development. Not every successful program screening process, where all the information that develops detailed policies about the same issues, is necessary to make an informed intake and although there are some common issues that all assessment decision is collected and considered. programs address (e.g., personnel, safety, etc.). The most successful programs initiate relationships However, what successful programs share in with their clients well before they formally enter common, is the attention that they give to figuring any particular program. During this time, plans are out and preserving what makes them successful. developed, expectations are clarified, and information is exchanged. It is evident that there is a good deal of overlap among the various formulations of Aboriginal health and 10.Pre-Admission and After-Care Programming healing best practices that have been attempted. This Successful healing programs recognize that a is a promising finding. Indeed, if there were widely healing experience, however effective, is but one diverging formulations, it would suggest there is little step along a healing path. Therefore, successful agreement. On the other hand, convergence around a programs use the resources at their disposal to work number of key principles and themes suggests that a
Chapter 2: Best Practices 29
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number of key best practices can, in fact, be identified, What is community development? and these can be used to guide successful program development. There have been many formulations. Here a few typical ones:
• Benett (1992; p. 3) has said that community development involves the “empowerment of The Community Development Approach individuals and their communities to better meet The most effective, long-term solutions to health and their economic and social needs.” social problems in Aboriginal communities have involved strengthening Aboriginal families, • Fairbarn et. al. (1991; p. 12-13) have described communities and nations. Health problems result from community development as involving “processes complex social, economic and cultural processes. of education and empowerment by which local Long-term solutions come about by addressing living people take control and responsibility for what used conditions, economic conditions, and social conditions, to be done to them . . . where other strategies of including education and employment opportunities. government and corporate business tend toward The focus of these efforts must be on creating and centralization, community development depends sustaining safe, secure, pro-social, and pro-health fundamentally on the greatest possible opportunities for individuals, families and decentralization of power, knowledge, control, and communities. This is the perspective on preventing wealth.” health problems and promoting health that accords • Community development has been described by with the experiences of Aboriginal communities, and Roberts (1979) as a process of learning - learning also with the latest thinking and research from those objectives, learning skills, and learning how to act who have examined population health determinants. and evaluate actions. It is the process whereby While all communities have social development needs, communities become aware of problems, sharpen it is important to recognize that the history and present perspectives through group discussion, clarify circumstances of each community is unique. objectives, carry out preliminary searches for Therefore, the social development plan in each solutions, screen options, choose actions, and community must also be unique. The fact of the matter evaluate outcomes. is that not all Aboriginal communities have serious • Nozick (1993) has described the community health problems. Many do not. And even where development process as involving three steps - self problems do exist, the nature, extent and character of awareness, community action, and linking with the problems, as well as the range of solutions that others outside the community. are possible, is unique in each case. Therefore, a “cookie cutter,” or “one-size-fits-all” approach is not Community development requires a substantial possible. Even though there may be many common measure of community control, a fact that accords concerns and aspirations, each community must assess well with the aspirations and rights of First Nations its own needs, be supported to learn from others and, and Metis peoples. Nozick (1993; p. 99) has described in the end, find its own way. what this means:
In this regard, it is helpful to review some of the community control means that the decision-making principles of community development, particularly process and organizational structures within a since Aboriginal communities are leaders in community are especially designed to give all community development practice. members of the community the power and means to manage their own affairs. Since society is
30 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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primarily organized on a top-down basis, • Achieve community ownership through the community control will necessarily require a involvement and commitment of community transformation from hierarchical to nonhierarchical members; structures so as to allow the maximum participation by community members in the decision making • Let community involvement and participation grow and development process. at its own pace as trust, new knowledge, and skills are developed; Community Development in Aboriginal • Insure community solutions are sustainable; Communities • Continually validate, evaluate, and correct the Many books and articles have been written about the process through community involvement and principles of community development. This is not the participation; place for a treatise on the subject. Yet, it is important to recognize that leadership in refining community • Work towards solutions, rather than towards development techniques and strategies has been programs or jobs as ends in themselves; coming from many Aboriginal communities, including communities in urban, rural, reserve, Northern and • Insure any assistance provided to the community remote areas (e.g., Northern Health Services Branch “facilitates” and “does with,” rather than “does 1992, Participatory Community Development for”; Committee 1992, Bopp and Bopp 1997a; 1997b; Hollow Water 1989; Hollow Water n.d.; Hylton 1995; • Remain open to new ideas and directions; 1993; Warhaft et. al. 1999; Ellerby and Bedard 1999). • Include awareness and skill development of Moreover, as will be discussed later, these approaches community members as part of the process; are currently being used by several Aboriginal communities to implement what are widely regarded More practically, community development in as the most effective and successful community Aboriginal communities has been conceptualized as responses to pressing health issues. involving several key steps:
Some of the essential principles of community • Deciding to change; development in Aboriginal communities that have been identified include the following: • Organizing to make change;
• Recognize and maintain traditional community • Establishing a core group; values and culture, including the involvement of Elders in “visioning” about the community; • Doing a needs assessment;
• Respect the strength and wisdom of community • Making a plan; members; • Getting commitments; • Insure the process and the conceptualization of • the issues to be addressed are holistic; Putting the plan into action; and
• Insure the process listens to community members, • Evaluating the changes that are brought about as a is flexible and respects the community “drum result. beat”; In addressing sensitive and complex health issues, it • Team work and networking must be a priority; is clear that the community must become motivated to take charge of its own future. Once motivated, the community will need to have the opportunity and
Chapter 2: Best Practices 31
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resources to analyze, to plan, and to implement some outside authorities and funders, the solutions. This may require the building up of local community was eventually able to gain support for infrastructures, including the identification and locally designed solutions through a process of development of a core group of committed ongoing dialogue; community leaders and Elders. Needed structures may already be in place, or they may need to be developed. • Agreement on future directions was reached, and Some communities may require advice, financial detailed guidelines, protocols and program designs resources, and a variety of other supports, for a short were developed. New initiatives were then piloted, or long time. adjusted and implemented;
When it comes to “best practices” in responding to • Throughout the implementation, the input of the health issues using community development principles, community was continuously sought to insure the the most promising approaches have been developed will of the community was being respected and by Aboriginal communities themselves using the initiatives were achieving the results that had Aboriginal community development principles. Two been hoped for.; leading examples of community responses to pressing health issues include Hollow Water and Canin Lake. • Ongoing evaluation and refinement was based not Like the well known Alkali Lake experience, each only on the input of external stakeholders, but also followed a similar pattern of development: the input of the community.
• Some members of the community decided that Supporting Communities Through the there was a pressing community problem and that Community Development Process something should be done about it. In different communities, different problems have been at the While each community is unique, it is apparent that root of the communities determination — suicide, there are many ways to assist communities in going drug or alcohol abuse, violence, crime, an absence through a process of self-assessment and of recreational opportunities, etc; development. For example, communities that have identified a pressing issue could be assisted with • A few leaders began to communicate, raise needed financial resources to move through the type awareness, consult, network and dialogue with the of community process that has proved to be effective community; elsewhere. These communities could be offered advice and assistance from others who have been through a • Over time, there was a growing community similar process. Tools that address specific issues, such consensus that something needed to be done; as needs assessment guides, detailed community development guides, public awareness materials, and • Research was undertaken by the community to sample protocols could be developed and made assess needs and possible solutions. An important available. Resource centers could be established to part of this research had to do with canvassing the house useful materials. community’s perceptions, attitudes and ideas; Indigenous community leadership and the • Possible solutions were taken forward to other development of local care providers is also very interested stakeholder groups and organizations important and requires support. Training opportunities within the community and beyond, such as could be provided for community leaders who want community leaders, justice system authorities, and to make a difference in their communities. potential funders; Communication and networking opportunities could be developed through conferences, newsletter and • Despite initial reluctance and even resistance by
32 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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other avenues so that leaders from different the “clusters” of key partner organizations that will communities have the opportunity to share knowledge support the initiative. These strengths should and experiences. include community strengths, such as elders, teachers, resource people, and a resource base of Others opportunities include affirming and restoring sacred knowledge and ceremony; communities through community health forums, healing ceremonies, and gatherings, and affording • Incremental Approach to Development opportunities for community representatives and Development should proceed in an incremental leaders to be involved in planning and decision making fashion. The vision may be broad and ambitious, forums. A number of specific action strategies but each step along the way must be reasonable incorporating these principles are outlined in Chapters and attainable; 4 and 5. • Core Staffing Requirements A core group of highly expert, interdisciplinary staff, including Indigenous knowledge experts, will be required. These individuals must be recognized Discussion as experts in their field by their respective On the basis of this analysis, it is possible to identify communities, and they should be eligible for cross- a number of best practices for developing and appointments with collaborating institutions; operating centres of excellence and Aboriginal health • Synergies Among Teaching, Research and and healing initiatives. These are available to guide Service the RQHR and its partners in their work. The centre’s programs should be designed to The key features of centres of excellence include the achieve synergies among teaching, services, and following: research;
• Clear Focus and Objectives • Diverse Partnerships and Relationships The proposed centre should clearly articulate and The development of numerous formal and delineate its areas of expertise. Centre programs informal partnerships and relationships should be should be organized to adhere closely to the centre’s a key objective of the centre. Broad representation mission and objectives; should be sought for various boards and committees that will have responsibilities for • Relevance of Objectives to Local Community directing and evaluating the centres programs; Whatever the importance of centre programs for others (the broader professional community, • Organizational Capacity governments, funders), these programs must, first The centre will require a number of key and foremost, reflect the priorities of the local organizational capacities. Provisions will have to community; be made for these capacities, whether the centre is to be part of a host organization, or a stand alone • Focus on Excellence enterprise. These key capacities include: 1) financial Whatever the focus, the centre should seek to be a administration, accounting and auditing, 2) human leader according to national and international resources, including: recruitment, staff training and standards; development, and personnel administration, 3) internal and external communications programs, • Building on Strength including publication programs and public The proposed centre should seek to focus on education programs, 4) access to advanced programs where existing capacity and expertise is technology, 5) access to libraries and resources already established, both within RQHR and within
Chapter 2: Best Practices 33
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centres, 6) access to decisions makers who set • The “centre of excellence” concept had overtones policy and allocate resources, and 7) financial and of competition and comparison. If one centre was other resources to carry out key research activities. excellent, presumably, others were less so, and It will also require the capacity to convene Elders inferior on some common scale. These ideas were and resource persons in the community to collect, not consistent with Aboriginal concepts of health analyze and transmit Indigenous knowledge; and healing. Advisors told us that health should be conceived of as a journey for individuals, families, • Evaluation, Feedback and Accountability communities and nations. The journey of one Appropriate provisions should be made to solicit should not be compared to the journey of another ongoing feedback from stakeholders. Monitoring nor conclude that one path was better or worse. and accountability frameworks should be established from the beginning. Evaluation criteria However, the concept of excellence was embraced, should be explicitly stated, and periodic not as an objective in and of itself, but as a goal to be independent evaluations should be conducted. achieved over time, by partners working together. Information about the activities and performance Stakeholders felt a welcome by-product of such efforts of the centre should be regularly provided to the would be the recognition of others. Thus, midway public, the professional community, funders, and through the project, the name of the project was other interested parties. changed from the “Aboriginal Health and Healing Centre of Excellence Project” to “The Working A centre with these features would undoubtedly be Together Towards Excellence Project.” able to quickly establish itself as a leading centre of excellence. A number of best practices of Aboriginal health and healing programs were also identified by the project As mentioned in Chapter 1, however, some of these team and advisors. These include best practices that conventional ideas about “centres of excellence” were might well apply to other types of health and healing abandoned during the course of the WTTE project. programs, as well as those that are unique to Aboriginal There were several concerns about the use of this programs. In particular, the following best practices concept in addressing Aboriginal health and healing may be noted: issues:
• The use of such a concept made it more difficult to get away from the notion of a physical facility A. Best Practices that Apply to Both or geographic location. As the partners worked Aboriginal and non-Aboriginal Health and together on the WTTE initiative, they felt a much Healing Programs more dynamic concept was required that would foster collaboration by many partners and 1. Learning Organization encourage networking through a virtual centre The organization plans, evaluates, uses evidence rather than a physical site; and strives for quality improvement;
• The idea of a “centre of excellence” may not 2. Program Effectiveness convey the sense of humility and respect for others Programs promote, prevent, protect, treat, and that leaders in Aboriginal health and healing felt detect early by employing effective assessment, should be a foundation for collaborative efforts to diagnostic, treatment and preventive tools and improve health outcomes. A centre of excellence approaches. Services are appropriately planned and was not something one set out to achieve, it was a delivered and are accessible to those who need reputation that could be earned, over time, if the them; right ingredients were brought together; and
34 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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3. Continuity of Service • The Programs are Rooted in Culture Programs have appropriate policies and procedures All aspects of the program (staffing, facilities, from first contact through to after care; governance, programs, etc.) recognize and affirm Aboriginal cultures and identity. This includes the 4. Client-Centered Approach active involvement of elders and traditional healers, Clients receive information when and where they and the importance of traditional healing and need it, including information about their rights indigenous knowledge to the endeavor; and how to exercise their rights. These rights are respected. Individual differences are recognized • The Strategies are Founded on a Recognition and respected. Individuals have the opportunity to of the Importance of Cooperation and choose the path that is best for them. Client needs Partnerships are well matched to the capabilities of the staff All aspects of the program recognize and affirm and the objectives of the programs; that interdisciplinary, multi-sectoral cooperation and partnerships are the foundation for successful 5. Appropriate Facilities Aboriginal health and healing initiatives. Facilities are appropriate to the program goals; • The Community has Voice 6. Appropriate Staffing Programs are community-based, they reflect the Staff resources are appropriate to the program priorities of the community, and they are goals and policies and procedures insure staff accountable to the community. Policies and development and staff effectiveness; governance assure not only community involvement, but community voice and community 7. Appropriate Administrative and Governance responsibility for program directions. Infrastructure An infrastructure of policies and procedures, and Experience to date also clearly indicates that successful an appropriate governance structure, insures programs grow from community development consistent, effective services are provided by the initiatives that are based on community development organization. principles. Aboriginal communities are leaders in this area, and they have clearly demonstrated that however well intended programs may be, they will have a limited B. Best Practices that Apply to Aboriginal impact unless communities have had an opportunity Health and Healing Programs to identify and assess the problems and solutions for themselves. While much can be done to support • The Goal is Equity communities that are interested in going through this The program strives to achieve equitable health type of process, there can be little progress if and social outcomes for Aboriginal people. Roles attempted solutions are externally imposed. and group processes are based on equity and fairness; Taken together, these best practices constitute a framework within which the RQHR and its partners • The Underlying Concept of Health is Holistic can develop a successful Aboriginal health and healing All aspects of the program are based on a holistic initiative for the region. concept of health that 1) takes into account physical, emotional, mental and spiritual dimensions of health, and 2) recognizes the interconnectedness of individuals, families, communities, and the environment;
Chapter 2: Best Practices 35
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36 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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CHAPTER 3 more effective ways? For example, could resources be better utilized through joint planning and prioritizing, sharing of funding and management support, or by the adoption of more Partnership “holistic” approaches to funding? Could additional resources be leveraged by working more closely together? If so, how could these changes be Opportunities brought about?
From the outset of the WTTE project, the RQHR Answers to these questions have been explored in recognized that it is only one among a number of key detail in First Nations and Métis Health and Healing stakeholders that must continue to work together if Services: Funding And Partnership Opportunities, a WTTE significant improvements in health and social background paper that is appended to this report and outcomes for First Nations and Métis people are to available on website http://www.rqhealth.ca . The be achieved. Therefore, one of the explicit objectives main findings of this analysis are presented here. The of the WTTE project was to engage other potential implications for the RQHR and its partners are further stakeholders in discussions about closer working examined in the next two chapters. relationships. The main purpose of this chapter is to discuss the progress to date in assessing these opportunities. The Opportunities for Partnership The RQHR has been concerned with a number of specific questions: The detailed analysis completed by the WTTE project team demonstrated that there are significant 1. Who are the stakeholders? opportunities for the RQHR to partner with other What government agencies (federal, provincial, organizations to improve health services and health municipal, First Nations and Métis ) and other outcomes for Aboriginal people. An overview of organizations are keenly enough interested or potential partners is provided in Table 3.1. already involved in Aboriginal health services that they would be interested in partnering with the These partnership opportunities arise because human RQHR on a significant new initiative? service organizations, whether they are federal, provincial or Aboriginal, face many similar goals, 2. What resources do these stakeholders have constraints and challenges. These organizations are available? increasingly coming to share a common philosophy What resources and expertise (funding, experience about the reforms that are needed to improve the and other resources) are available from these quality and effectiveness of human services for stakeholders that could be brought together and Aboriginal people. Some elements of this “common focused on the further development of effective ground” include: health services for First Nations and Métis peoples? Are there barriers that are preventing stakeholders 1. All agencies are having to operate within a climate from working more effectively together? If so, what of fiscal restraint, and all are under increased are these barriers and how can they be overcome? pressure to demonstrate that what they do really makes a difference. Agencies know that meaningful 3. How are resources currently being utilized new initiatives increasingly require stakeholders to and what alternatives might be considered for pool efforts and resources; channelling existing and new resources in
Chapter 3: Partnership Opportunities 37
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2. There is a recognition that social programs have interest in integrated, holistic approaches to placed too much emphasis on responding to the problem solving that will build collaboration across “symptoms” of social disintegration, and not longstanding government and agency boundaries; enough on the underlying, “root” problems; 5. There is an interest in promoting more community- 3. Agencies are discovering that the problems that based and less institution-based approaches to give rise to demands on their programs often have addressing problems in the community; to do with the quality of community and family life, and that the real challenge is to build healthy 6. There is interest in promoting more equitable families and communities; access to a range of health, social, justice, education, employment and other services, and a 4. Conventional approaches to program design, where recognition that Aboriginal people are often different agencies respond to specific problems, are significantly disadvantaged in obtaining services increasingly seen as inadequate. There is increased because of their personal and family circumstances,
Table 3.1 Overview of Partnership Opportunities
Federal Government Agencies Provincial Government Agencies Health Health Indian Affairs Social Services HRDC Justice Justice Learning Solicitor General Government Relations and Aboriginal Affairs Heritage Status of Women Correctional Service Post-Secondary Institutions RCMP Industry and Resources Statistics Canada Crown Corporations Canadian Institutes of Health Research Privy Council Office Other Agencies CMHC Municipal Governments School Boards Aboriginal Communities, Governments, and Private Sector Organizations Charities First Nations Governments Non-Government Health and Social Agencies Métis Governments Foundations First Nations Agencies Community-Based Organizations Métis Agencies First Nations Communities Métis Communities National Aboriginal Health Organizations Aboriginal Education and Post-Secondary Institutions Aboriginal Healing Foundation Urban Aboriginal Organizations
38 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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geographic isolation, cultural barriers, and a variety even among departments and agencies within the same of other factors; governments) about who is responsible for providing and funding Aboriginal services has led to a complex 7. The limitations of centralized program design and web of programs, funding mechanisms, and eligibility top-down administration are also increasingly being criteria across the country. While these arrangements recognized. There is interest in decentralized have sometimes resulted in a level of service for
decision making and service delivery structures, Aboriginal people ○○○○○
and an acknowledgment that solutions that work that approximates ○○○○○○○○○○○○○ are owned by the community. This has translated that available to There is a desire to into a renewed interest in promoting “community non-Aboriginal development” strategies; and Canadians, more develop more effective often these 8. The right of Aboriginal people to govern their own jurisdictional working relations between affairs is being affirmed and the necessity of disputes have led to Aboriginal organizations and governments large gaps in Aboriginal governments becoming much more involved in designing and services for and organizations and delivering programs for Aboriginal people is being Aboriginal people. recognized. There is a desire to develop more mainstream human service effective working relations between Aboriginal Jurisdictional governments and organizations and mainstream disputes have systems human service systems. tended to produce inaction on the part Increasingly, partnerships are viewed as an essential of all levels of government, and frustration for strategy for increasing effectiveness across Aboriginal people. If there is a disagreement about longstanding bureaucratic and programmatic barriers. which level of government is responsible for a Some partners can bring the expertise and authority particular service, all levels of government have been that will be needed to find more integrated, holistic willing to delay action in the hope that the problem solutions to community problems. Some will have will be addressed by someone else. And when significant financial resources to contribute. Some will governments do respond in areas of disputed bring the community involvement and ownership that jurisdiction, their response very often only deals with is essential to designing and implementing programs. an immediate crisis; it fails to provide the long-term All must bring their contributions to create an effective solutions that are needed. mix of knowledge, financial resources and credibility. A thorough analysis of jurisdictional issues in the field of Aboriginal health would be a complex and time consuming undertaking involving, among other things, an extensive review of the legal issues involved. Some Obstacles to Moving Forward of this analysis has been completed, and it is a part of a growing literature on Aboriginal jurisdictional Two significant obstacles to establishing partnerships questions. But the purpose of this discussion is not and moving forward with a significant Aboriginal to summarize this literature. Rather, the intention here health initiative may be identified. These have to do is much more limited. It is to examine the implications with uncertainty about jurisdictional responsibilities of the current jurisdictional impasse for the Aboriginal and the shortage of Aboriginal human resources. health initiative being contemplated by the RQHR, Jurisdictional Issues and to suggest some practical strategies for overcoming these constraints. Disagreements among Canadian governments (and
Chapter 3: Partnership Opportunities 39
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In order to gain an appreciation of the jurisdictional law in regard to Indian property and Indian education disputes that have been referred to, it is necessary to (areas that would normally fall within provincial briefly review some of the provisions of the Canadian jurisdiction) have traditionally been part of federal Constitution and of the Federal Indian Act. The Indian policy, and could no doubt be justified as a Constitution is important to the present discussion federal responsibility because they aim at particular for at least three reasons: 1) for what it says about Indian concerns. Similarly, it is probable that if the jurisdiction over health, 2) for what it says about who federal government chose to legislate in the area of is an “Indian”, and 3) for what it says about who has First Nations health programs, it would have the jurisdiction over health and other services for Indians. authority to do so. An understanding of the Indian Act is necessary to gain an appreciation of the legislative and policy Importantly, the federal government is not compelled regimes that have been established by the federal to act in areas where it has jurisdiction, and in many government, and how this results in the federal areas of Aboriginal services, it has chosen not to enter government providing the field, at least in a legislative capacity. In the absence
○○○○○○○○○○○○○○○○○ only some services to of federal legislation, provincial laws generally apply to Indians, as they do to any other citizens. Any doubt Although the federal only some Aboriginal groups. about this has been resolved by section 88 of the government has shown Indian Act which states: While the Constitution considerable reluctance is silent on many Subject to the terms of any treaty and any other Act of the Parliament of Canada, all laws of general to enter many areas of issues, it does explicitly set out a jurisdictional application from time to time in force in any Aboriginal human framework in relation province are applicable to and in respect of Indians to the health field. The in the province, except to the extent that such laws services in a legislative constitution is clear are inconsistent with this Act or any order, rule, regulation or by-law made thereunder, and except capacity, it has been that health services are a responsibility of to the extent that such laws make provision for quite willing to exercise provincial any matter for which provision is made by or under this Act. its spending power in governments. The federal government has been reluctant to enact some of these same Were these the only specific legislation to deal with a whole host of relevant constitutional Aboriginal human service issues ranging from health areas provisions, the main and social services, to child welfare and justice issues. responsibility for Therefore, provincial laws in these areas usually apply. overseeing health services affecting Aboriginal people would clearly rest with provincial governments. Although the federal government has shown However, in separate constitutional provisions, the considerable reluctance to enter many areas of federal government is given specific responsibility for Aboriginal human services in a legislative capacity, it Indians. In particular, Section 91(24) grants the federal has been quite willing to exercise its spending power government the jurisdiction to legislate with respect in some of these same areas. This has occurred in to “Indians” and “lands reserved for Indians”. relation to programs delivered directly by the federal government, as well as through the cost-sharing of Section 91(24) grants the federal government programs that are delivered by others — historically, additional authority and responsibility for “Indians” provincial and territorial governments, but, beyond the authority and responsibility that the federal increasingly, Aboriginal institutions. This spending government has for Canadians generally. For example, power has been used to help fund programs of general
40 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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application (medicare, social programs, income The Indian Act is also relevant to the present security programs, post-secondary education, and discussion because of its provisions (past and present) others), and it has also been used to partially or wholly relating to the determination of Indian status. Over fund programs specifically intended for the benefit of time, distinctions have been introduced between status Aboriginal people. Most of these latter programs have and non-status
been for on-reserve Indians and Inuit, although there Indians. It is by no ○○○○○○○○○ have been some notable exceptions (e.g., Aboriginal means clear that ○○○○○○○○○○○ employment and training initiatives, addictions the courts would The federal government has programs, the Native Courtworker Program, accept these Friendship Centres, and others). various sub- taken the position that categories in all provincial law should address According to the federal government, at least with instances, and, at respect to off-reserve Indians and Métis, the extensive least in some the health, justice and social funding it has provided for Aboriginal human services instances, there is programs reflects government policy. The federal a basis for needs of all citizens, government does not acknowledge any legal disputing their including the Aboriginal responsibility to provide this funding. Therefore, it has legitimacy. Faced reserved for itself the right to change levels of funding, with the prospect peoples as well as funding priorities, without any agreement of court from Aboriginal people or from provincial or territorial challenges governments. The federal government’s approach was relating to the status of Indian women who had evident, for example, in decisions over the past decade married non-Indians, for example, the federal to discontinue federal funding to provide social government enfranchised many previously excluded assistance for off-reserve Indians. This policy was from “status” through the adoption of Bill C-31. changed even though the provincial governments and the Aboriginal organizations affected, were adamantly The federal government has also introduced opposed. distinctions between on-reserve and off-reserve Indians. While off-reserve Indians continue to benefit Further confusion over jurisdictional responsibilities from a few federal programs (e.g., the Non-Insured results from the fact that the precise meaning of the word “Indian” in the Constitution is disputed. In 1939, Health Benefits Program), they are not eligible for most the Supreme Court determined that “Indian” in section of the programs that the federal government funds 91 (24) of the BNA Act included Eskimo (as they for on-reserve Indians. In addition, as pointed out were then termed) inhabitants of Quebec. In addition, earlier, federal funding formula used to determine however, some analysts have suggested that the courts grants to First Nations usually take account of only might favour an interpretation that the Métis people those residing on reserves, not the total memberships also fall within the meaning of “Indians.” While this of Bands. Because of the increasing proportion of interpretation would be consistent with subsection 35 the Indian population that resides off-reserve, this (2) of the Constitution Act, 1982, which defines the distinction has allowed the federal government to avoid Aboriginal peoples of Canada as including “the Indian, responsibility for an increasing proportion of the Inuit and Métis peoples of Canada”, this proposition Indian population. has never been tested before the courts. As a result, the federal government does not acknowledge the These various provisions of the Canadian Constitution same responsibilities for the Métis as for Indians and and the Indian Act, combined with an absence of a Inuit. This is reflected in dramatic differences in the clear agreement about who is included within the scope financial support provided by the federal government of federal, provincial and territorial responsibilities, to various Aboriginal peoples. has set the stage for disagreements among
Chapter 3: Partnership Opportunities 41
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governments and within governments about who complex funding and administrative arrangements should take responsibility for funding various services. have been developed over the years to allow Because of the provisions of Section 91(24) of the governments to contain their costs and minimize their Constitution, provinces and territories, throughout the responsibilities. These arrangements, which have been history of confederation, have looked to the federal encouraged by the general climate of fiscal restraint, government to exercise jurisdiction over a variety of have excluded Aboriginal people from programs that, social and health matters affecting Aboriginal people. in the view of a particular government or department, The federal government, on the other hand, has taken should be the responsibility of another department the position that provincial laws of general application or government. As a result, a service that may be should be in place to address the health, justice and generally available to Canadians may not be available social needs of all citizens, including the Aboriginal to Aboriginal people because no one can agree who is peoples. responsible for funding or providing the service. This too often has led to paralysis when it comes to Through changes in policy, those who benefited from developing innovative, culturally appropriate services the exercise of the to meet the specific needs of First Nations and Métis
○○○○○○○○○○○○○○○○○○ federal spending peoples. Either level of government could enact laws, power in the past have Aboriginal peoples believe institute programs, and allocate resources, but, in many been excluded from instances, neither level of government has elected to the federal government some programs do so. In the end, there is a failure to provide services because they are not and produce outcomes at standards that are expected has a general fiduciary “status” Indians, or in non-Aboriginal communities. Aboriginal because they reside communities are caught in the middle. responsibility to safeguard off-reserve. In turn, the provinces have their rights and well-being In summary, current institutional and jurisdictional interpreted the federal arrangements between levels of government: government’s policy changes as an attempt • Divide individuals and groups based on legal status to “off-load” its responsibilities, and the associated and residency; costs and, therefore, they have often resisted funding adequate services for the Aboriginal peoples. • Divide jurisdiction between federal departments, and between federal and provincial/territorial First Nations believe that the federal Crown has a governments in ways that segment needs and responsibility to honour Treaties, and all Aboriginal preclude holistic approaches to problem solving; peoples believe the federal government has a general fiduciary responsibility to safeguard their rights and • Provide very limited coordination among services; well-being. In the view of many Aboriginal leaders, the federal government’s policy of off-loading • Invite attempts by governments and service responsibility for some services onto provinces and providers to constrain costs by denying services territories is also an attempt to abandon federal or by attempting to off-load responsibility on other fiduciary and Treaty responsibilities. But the federal governments or departments, or directly on government has adopted the position that Crown Aboriginal communities; responsibilities in Canada are now divided between federal and provincial levels of government and, • Push up costs for the provision of remedial therefore, provincial governments must accept their services, while, at the same time, failing to prioritize fair share of Crown responsibilities. preventative and community development approaches that would be more cost-effective and Reflecting the above noted disputes, a myriad of culturally appropriate;
42 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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• Disempower Aboriginal individuals, communities provincial governments. They may need to be and nations; persuaded that projects like the one being pursued by the RQHR present opportunities for both levels of • Largely fail to recognize or respect the rights of government to show leadership through a joint Aboriginal people to be self-determining; and initiative that will be mutually beneficial for all partners.
• Reinforce negative aspects of differences (race, Creative approaches
ethnicity, culture) among majority and (so-called) such as those ○○○○○○○○○○○○○○○○○○ minority groups, thus promoting fear, animosity demonstrated in the The development of more and mistrust. North and in Fort Qu’Appelle namely, effective strategies will A resolution to these issues is vital to improving health the Northern Health require flexibility on the services for Aboriginal people. If these jurisdictional Strategy and the new questions are not resolved, the pattern of inaction and Fort Qu’Appelle part of both federal and sub-standard services is very likely to continue. Indian Hospital under construction, are provincial governments Regrettably, current provincial government policy does required. For example, not provide the best framework for overcoming the enriched federal kind of entrenchment that has been described. The financial participation could be sought for the provincial government’s Aboriginal Policy Statement dimensions of the initiative that pertain to First says, in part: Nations, especially for First Nations peoples residing on reserves, while the province and the RQHR might Within the Constitution, the Parliament of Canada show flexibility in developing mutually agreeable mix has the specific power to make laws in relation to of funding for programs for Métis and off-reserve Aboriginal peoples; provincial legislatures do not. Aboriginal people. The goal should be to obtain The federal Crown, through Parliament, also has financial participation from the federal and provincial special trust-like, fiduciary, and financial obligations governments without getting bogged down in a to Aboriginal peoples; provincial legislatures do not jurisdictional dispute. . . . (current) partnerships . . . recognize the federal government’s primary jurisdictional, fiduciary, Some provinces have shown a willingness to be flexible constitutional and financial responsibilities as they in their policy positions on a case-by-case basis. It is pertain to Indian and Métis peoples. worth noting that, several provinces have reformulated their approach to Aboriginal jurisdictional and funding However necessary to the integrity of the provincial issues. In both Ontario and Alberta, for example, government’s federal-provincial, financial and significant provincial funding has been provided for Aboriginal policies this position may be, from a dedicated Aboriginal health programs, even while practical standpoint, it does not provide a basis for policy positions regarding the federal government’s building new and effective partnerships with the federal responsibilities for Aboriginal health have not changed. government or with Aboriginal stakeholders. At an operational level, however, these provinces have Depending on the direction of the Aboriginal health recognized the financial and human costs of initiative, the RQHR could be caught in the middle of maintaining the status quo. these jurisdictional issues, and may have to request a review of current policies. Human Resources
The development of more effective strategies will Throughout this report, the importance of the full require flexibility on the part of both federal and and active involvement of Aboriginal people in the
Chapter 3: Partnership Opportunities 43
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Health Authorities initiative has been referred to. This • Aboriginal organizations and governments have involvement must extend to all levels and stages of recognized the importance of human resources planning and implementation — designing of the development, and they have sponsored numerous initiative, making decisions about the allocation of conferences, workshops, in-service training resources, developing specific program proposals, and opportunities, continuing professional actually implementing the various services that will development programs, youth fairs and other be needed. Without this involvement, the initiative is events, designed to attract, train and retain doomed to be another ineffective attempt by the Aboriginal staff in key human services roles; and mainstream system to improve services for Aboriginal people. However well intentioned, it will not succeed • Some mainstream employers, including the RQHR, in achieving the RQHR’s objectives. have had some success in hiring Aboriginal staff who have then gone on to gain invaluable training The RQHR must continue to recognize that Aboriginal and experience in health services. involvement is essential to the success of the initiative, but it must do much more. Acting with other A number of initiatives have also been initiated by the stakeholders, it must continue to ensure that the RQHR to foster the development of Aboriginal human resources that will be needed are made human resources. A good example, is the RQHR’s available, and it must continue to take the necessary Representative Workforce Program.1 steps to secure Aboriginal involvement. The capacity of Aboriginal people to design and provide needed Important human resources development strategies services must continue to be increased through a that need to continue to be pursued, include: substantial and ongoing commitment to the development of Aboriginal human resources. This 1. Increasing the capacity and number of education “capacity building” should continue to be an important and training programs that are provided by dimension of all the relationships that governments Aboriginal institutions; and mainstream service agencies establish with 2. Focussing on the support of successful outcomes Aboriginal governments and organizations. at the elementary and secondary school levels; During the past number of years, there has been a 3. Improving the contributions to the development significant increase in the number of suitably trained of Aboriginal human resources that are made by Aboriginal people capable of assuming important roles mainstream education and training programs; in the design and delivery of health services in Saskatchewan. This has occurred for several reasons: 4. Improving Aboriginal students’ ability to pursue education and training through the provision of • Aboriginal post-secondary institutions, such as the financial and other supports; Saskatchewan Indian Federated College, often in partnership with universities, have given priority 5. Improving the cultural appropriateness and to training Aboriginal students in social work, the effectiveness of education and training programs sciences, nursing, education and related fields; so that they better meet the needs of Aboriginal students and Aboriginal communities; and • Mainstream universities and other post-secondary institutions have increased their efforts to attract 6. Providing opportunities for on-going professional and retain Aboriginal students (e.g., the Aboriginal development and career advancement. Nursing Programs at SIAST and the University of Saskatchewan); 1 See: Regina Health District (2002). Representative workforce program: Fifth annual report. Regina: Regina Health District
44 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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As a consequence, the status of Aboriginal human A related challenge has to do with creating a culture resources in Saskatchewan is now much improved over within the RQHR that is supportive of traditional than in years past. Aboriginal healing ways and practices and of Aboriginal employees. It cannot be taken for granted At the same time, many questions remain about the that all employees, managers, physicians, contractors, available resources. board members, volunteers and others have had the opportunity to develop the knowledge and • Are sufficient Aboriginal human resources available understanding that are required to be supportive. In to support the requirements that will be associated fact, experience suggests some likely harbor negative with the RQHR’s current programs and future racial stereotypes. Working within an organization as
initiatives? large and diverse as RQHR to create this type of
○○○○○○○○○ supportive ○○○○○○○○ • While there are an increased number of Aboriginal environment people who have experience in direct service represents a significant A challenge for the undertaking in and of delivery, are there adequate resources to ensure the RQHR is to create a Aboriginal planners, program designers, itself. administrators, and evaluators of tomorrow? culture that is supportive While the RQHR has • Are the currently available human resources a vested interest in of traditional Aboriginal capable and willing to meet program requirements ensuring human healing ways and where Aboriginal people live, including in rural, resource needs are remote, and urban communities? addressed, many other practices and of stakeholders will A comprehensive approach to the development of continue to be Aboriginal employees Aboriginal human resources was being developed for available to work on the former Regina Health District. Now, this initiative these issues. These needs the resources to carry on so that implications include Aboriginal and non-Aboriginal post-secondary within the much larger RQHR can be addressed. While institutions, Aboriginal governments and formal programs of study offered at post-secondary organizations, the provincial education, employment institutions make an enormous contribution, by and training agencies, the federal Human Resources themselves, they will not be enough to overcome the Development Department, SAHO, and many others. many needs for enhanced human resources. More flexible approaches to support local training and Once needs within the new RQHR have been properly human resources development are also needed and assessed, the RQHR should consider being a leader should continue to be pursued. These could take the in promoting Aboriginal human resources form of supporting local and regional Aboriginal development. This could take the form of continuing organizations to organize workshops, conferences, and to support Aboriginal students, for example, to other training events that address critical health issues. undertake appropriate training in areas where there These types of approaches can be used to provide are critical shortages, by providing internship and training and support with respect to traditional mentorship programs within the RQHR, by seconding Aboriginal practices, to address special training needs staff to work with Aboriginal governments and of those working in rural communities, to address high organizations, and by providing support for priority areas of concern such as family violence and community training events. Of course many such substance abuse, to encourage local and regional activities are already underway, but they can be planning, and for a variety of other worthwhile expanded. Other approaches might focus on the purposes. retention of current Aboriginal employees, providing
Chapter 3: Partnership Opportunities 45
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opportunities for these employees to network with The RQHR’s financial commitment is important for other Aboriginal service providers within and outside at least two related reasons. the RQHR, and examining job descriptions and classifications to insure that indigenous knowledge and 1. Without a strong commitment, the RQHR will lack experience working in Aboriginal communities is credibility with potential partners. If improving appropriately recognized and rewarded. Because Aboriginal health outcomes is not a financial and improvements in the area of human resources are organizational priority for the RQHR, why should critical to the RQHR’s objectives, it should not be a others make the sacrifices and trade-offs that will bystander when it comes to ensuring these needs are be necessary to make it a priority within their appropriately addressed. organizations, especially when there are so many other issues that also need to be addressed? Put There are also opportunities at the provincial level. another way, if it is willing to make a significant The RQHR’s continuing involvement in SAHO’s financial commitment, the RQHR will send a clear initiatives, and in the Provincial Council of message to potential partners that it is serious about Representative Workforce Co-Ordinators are two such moving forward. Other organizations will then opportunities. want to examine how they can achieve their objectives through collaboration with the RQHR in a way that would not be possible otherwise. This is the kind of synergy that the RQHR must seek The Challenge to encourage. However, if the RQHR has no resources to bring to the partnership, potential While there are significant opportunities for partners may show limited interest and collaboration with other organizations, the RQHR will commitment; have to better position itself if it wants to take advantage of these opportunities. Turning “potential” 2. As other organizations become involved in the into real and productive partnerships will require a development of joint plans and priorities, there will careful review of priorities, plans and capacities. be many competing ideas about how to proceed. Each agency will see problems and solutions from The RQHR is rightly interested in knowing about the a unique vantage point. The RQHR’s ability to contributions that other organizations can make to influence program design and implementation so improve Aboriginal health outcomes, but the RQHR that its concerns and priorities are addressed will must also be prepared to weigh-in with a visible and depend, in part, on the extent of the commitment significant commitment of its own. This commitment the RQHR is prepared to make. could take a number of different forms. It will involve welcoming change, financial commitments, How should the RQHR go about making a financial commitments of organizational capacity, a willingness commitment? Only a general discussion is possible to articulate a plan of action that could form the basis here, since the final answer to this question will depend of discussions with other stakeholders, a willingness on the details of the initiative the RQHR decides to to share power and resources with potential partners, proceed with. However, as discussed further in or, most likely, a combination of these approaches. Chapter 4, joint planning and action, as well as joint Any or all of these actions will demonstrate the ownership and responsibility for outcomes, implies the RQHR’s continuing commitment, but, more joint commitment of resources on the part of all the importantly, such actions would increase the RQHR’s partners. Thus, while RQHR must face the resource ability to improve Aboriginal health outcomes through challenge, other partners who wish to participate in meaningful partnerships with other organizations. taking joint action to improve First Nations and Métis health outcomes will also have to address the resource
46 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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issue. Moreover, partners will have the opportunity to • Develop specific objectives and monitor progress develop new strategies for obtaining incremental towards their achievement; resources, as well as for the use of existing resources. • Plan and implement strategy with respect to the Some agencies who are extensively involved in involvement of other stakeholders; providing Aboriginal human services take the position that they cannot improve services for Aboriginal • Dialogue with communities and organizations to people unless incremental resources are provided to determine their capacities and interests; them. This approach fails to recognize that existing resources are already being disproportionately • Produce specific plans and proposals; allocated for the purpose of providing services to Aboriginal people. It also fails to recognize that existing • Design, implement, fund, administer and evaluate programs often do not achieve the desired outcomes, specific initiatives; even though the costs of maintaining these programs • goes up every year. By making reforms contingent on Disseminate plans to decision makers and the availability of new resources, especially in a climate communities; and where new resources are not always available, these • Consult with numerous stakeholders on an ongoing agencies are choosing to maintain the status quo. basis. Given the current fiscal realities, it may not be possible It is also important to point out that opportunities to to obtain major new resources for Aboriginal health partner with other organizations do not remain static services. While some new funding may be found, it is over time. On the contrary, these opportunities shift probable that resources will also have to be reallocated depending on available resources and the evolving from within existing budgets. Reallocation of resources policies, programs, and priorities of organizations. will not be easy, however, in the current climate, there They also depend on less tangible factors that are also may be little alternative. subject to change, such as the interests and capacities of those in leadership positions. At the same time, working together, the partners should seek out incremental financial resources from At present, the partners have limited capacity to other stakeholders, notably the provincial and federal respond to these challenges. This capacity is not nearly governments, in the areas that have been identified adequate to carry out the responsibilities that have throughout the discussion in this chapter. Ideally, a been enumerated. With the exception of a few staff blend of new and reallocated resources can be who have become specialists in Aboriginal health and combined with the commitments of other community issues, most of the enumerated organizations to create significant support for a new responsibilities have no “home” within the RQHR initiative. structure or within any other organization, or they fall on the shoulders of officials who have many other As discussed more fully in the next two chapters, the duties and priorities. This arrangement does not reflect partners must also review their current organizational the importance that the partners attach to the capacities to move forward on Aboriginal health issues. improvement of Aboriginal health outcomes. Developing the potential partnerships that have been identified, and overcoming the obstacles that have been It will be necessary to develop a specific plan. Elements discussed, will involve the participation and of this plan might include: cooperation of numerous stakeholders in a very complex field. The partnership will require a capacity • More Aboriginal involvement and control of to: programs for Aboriginal people;
Chapter 3: Partnership Opportunities 47
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• More Aboriginal people involved in planning and RQHR will need to have a practical and workable service delivery; approach to address current jurisdictional issues. This must involve a strategy that offers more flexibility than • An increased reliance on alternatives to institution- the provincial government’s current Aboriginal policy. based services; Secondly, the RQHR will have to take steps, in cooperation with other stakeholders, to ensure that • More culturally relevant and appropriate programs human resource implications are properly assessed. for Aboriginal people; An appropriate plan of action must be put in place to address these needs. By dealing with these issues head • Greater emphasis on the prevention of illness; on, the RQHR and its partners can avoid being sidetracked by challenges that are certain to arise during • More involvement in promotion and early the formulation and implementation of plans for intervention; improving Aboriginal health outcomes.
• Greater use of traditional Aboriginal practices and It will also be necessary to start a new chapter in ways greater reliance on traditional Aboriginal concepts of thinking about the challenges and opportunities of health; that lie ahead. Instead of viewing health and health outcomes as a prerogative of care providers and the • Strategies that will lead to improvements in the health region, RQHR has the opportunity to recognize return on investment in current health services for there is a much more effective approach. It relies on Aboriginal people; and working closely with a broad group of stakeholders, including First Nations and Métis governments, to • Clarification of roles and responsibilities among ensure health problems and solutions are jointly various provincial, federal, and Aboriginal identified, jointly addressed, and jointly “owned.” stakeholders. Exploiting current and future opportunities, while The partners must not only become clear about their overcoming the obstacles that have been discussed, specific objectives (over time and in consultation with has significant implications for the RQHR’s and its other stakeholders), but they must have the capacity potential partners. These implications, which are to ensure plans are implemented and specific outcomes discussed in the next Chapter, will have to be addressed are achieved. as plans are developed and relationships with other stakeholders are pursued.
Conclusion This analysis reveals that there are many organizations who are potential partners with the RQHR in improving health outcomes for Aboriginal people. The opportunities to work together with these organizations should be fully explored because far more will be achieved by working with these stakeholders.
The challenges are significant. Firstly, in working with provincial, federal and Aboriginal governments, the
48 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Chapter 3: Partnership Opportunities 49
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50 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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CHAPTER 4 specific opportunities to significantly improve the effectiveness and appropriateness of RQHR services for First Nations and Métis people, particularly primary health care services. By themselves, these Towards improvements will not address health determinants, but they are an important part of a comprehensive plan. The intent is to improve quality by: 1) building Collaboration partnerships, 2) incorporating best practices, 3) ensuring services are evidence-based, and 4) improving The next two chapters set out two broad and information for planning purposes, and 5) carefully complimentary strategic directions for the RQHR and assessing outcomes. This second strategic direction is its partners to consider. Each chapter also discusses discussed in Chapter 5. some of the specific steps that are required to implement these directions.
The strategic directions discussed in the next two Starting with Common Values and chapters build on findings reported earlier in the Objectives report. In particular, they take account of best practices, partnership opportunities, major obstacles, Improving First Nations and Métis peoples’ health community development principles, and insights from outcomes requires that organizations work together both the internal and external consultations. These to address the social, economic, cultural, and other strategic directions identify how the RQHR and its determinants of health. No change in the method of partners can best go about addressing the need for organizing and delivering health services will, by itself, improvements in First Nations and Métis health result in the better outcomes the RQHR and its outcomes. partners seek.
The first strategy, which is discussed in this chapter, In the past, effective collaboration on major population outlines a framework for joint planning, joint decision health issues has often been difficult to achieve because making and joint action with key organizations that of the complex array of organizations, governments, share concerns about First Nations and Métis health funding sources and jurisdictions that have evolved outcomes. The proposal to establish a “collaborative over many years. These organizational and structural framework” reflects the fact that Aboriginal health impediments must be addressed so that more joint outcomes largely result from social, economic, cultural planning, joint decision making, and joint action can and other “determinants of health” over which any occur. The purpose of the “collaboration framework” one organization has quite limited control. Thus, is to establish an ongoing mechanism for bringing key collaboration with other organizations, including First partners together to overcome these obstacles. Nations, Métis, municipal, provincial and federal governments, is essential if progress is to be made on It is self evident that, to be effective, those involved broad issues that impact on health status. It is in a partnership must share common objectives, as recommended that the RQHR and a number of other well as common beliefs about how the objectives can key organizations, including First Nations and Métis best be attained. Without basic agreement on these governments, take a lead role in establishing such a fundamentals, the prerequisites for building a framework. partnership will not be present. Can such common ground be found among the partners who need to be While the Collaboration Framework is forming, and involved in a significant Aboriginal health and healing even after it begins operations, there are a number of initiative? Based on the collaborative work of the
Chapter 4: Towards Collaboration 51
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WTTE project over the past eight months, there is The partners want to develop and implement more reason for considerable optimism! effective systems of culturally appropriate services, because the partners believe that they will help First Throughout the WTTE project, numerous Nations and Métis people restore, maintain and consultations were held with potential partners to improve their health and well-being; sketch out common ground — common objectives, commonly perceived obstacles, and commonly held The partners want to address the “determinants views about strategies and opportunities for moving of health,” and particularly social and economic forward. In addition, the diverse members of the conditions, because the partners believe that they project’s External Advisory Committee spent a have an important influence on health outcomes; number of months working together on these issues. While the results are not in their final form and will The partners want to strive for excellence in service evolve as the partnership itself evolves, a starting point delivery, because the partners believe this is the for working together has been firmly established. best way to achieve positive outcomes;
Throughout the discussions and consultations, it The partners want to build First Nations and Métis became clear that neither the province nor the region human resources, research, and service delivery could attain its social or economic goals without the capacity, because the partners believe this is the full participation of First Nations and Métis citizens. best way to achieve excellence; In fact, drawing on the significant strengths and capacities of First Nations and Métis communities, The partners want to employ best practices organizations, and governments was seen by all whenever possible, because the partners believe participants as an essential strategy for ensuring the best-practices insure the most effective use of health and prosperity of all people within the province. available resources;
The emerging consensus about goals and objectives The partners want to work together because the is best described in the agreement that was reached partners believe much more can be achieved than on a number of key questions about the collaboration: by working alone.
I. What is the Partner’s Mission? Why do the III. What Will Guide the Partners as We Travel Partners Want to Work Together? Together Along the Path We Have Chosen? What Are Our Shared Beliefs and Values? The partners want to help ensure that First Nations and Métis people attain fair, equitable and just The partners believe in the Creator and that the health and social outcomes that are at least Creator is the source of our strength and comparable to those of other groups in society. inspiration;
II. What do the Partners Consider to be the Key The partners believe that we have a common Strategies That Must be Pursued to Achieve purpose and that we can make a difference; the Mission? The partners believe that mutual respect for each The partners want to support First Nations and other and for the jurisdictional responsibilities and Métis families, communities and nations in their autonomy of our organizations is a foundation for efforts to restore their strength and vitality, because our work together; the partners believe these are the foundations for health and healing; The partners believe that health is a right of every
52 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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family, community, and nation, and that we must The partners believe we can work together by take responsibility for our own health, while also consensus, while resolving differences through helping others; open, honest and respectful dialogue;
The partners believe that health is about much The partners believe that effective partnerships more than illness, disability or disease. The partners require a commitment from each partner that is believe in the importance of First Nations and commensurate with the resources, knowledge and Métis understandings of holistic health — that skills of that partner; health has physical, emotional, mental and spiritual dimensions; The partners believe that every member of the partnership must be committed to its success, and The partners believe in the importance of that we will all have to put forward our best efforts traditional First Nations and Métis healing to make the partnership work; knowledge and cultural practices; The partners believe that we can take charge of The partners believe Western, First Nations and our future if we take joint responsibility and joint Métis health and healing traditions can draw on ownership for the decisions that the partners arrive inherent strengths and compliment one another; at together;
The partners believe we can learn from and support The partners believe in following up our one another and build on the strengths of each commitments with action; partner. The partners believe diversity is a source of strength; diversity is a common gift to be The partners believe in being accountable to the honored, celebrated, and relied upon for the benefit community and to those the partners serve; of all; The partners believe that success fosters success, The partners believe in community involvement and that our successes together must be recognized and inclusiveness. We want to seek ways to and celebrated; meaningfully involve citizens as individual, families, communities and nations in the development of 4. What do the Partners Hope to Achieve by services that encompass prevention, care, Working Together in This Way? treatment, and support for whole health; Our relationships with one another and our The partners believe in being innovative, creative, partnership will strengthen; flexible, productive and effective; First Nations and Métis health and social outcomes The partners believe that partnerships are based will improve; on trust and respect, that they are fluid, dynamic and evolving, that they are mutually supportive, First Nations and Métis peoples will make an and that they must be nurtured and renewed over increasingly important contribution to time; Saskatchewan’s prosperity and well-being;
The partners believe that every member of the Resources will be used more effectively; collaboration is an equal partner, and that it is both possible and desirable to share power and The partners will be recognized by those we serve leadership amongst diverse partners; as having provided leadership; and
Chapter 4: Towards Collaboration 53
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Our partnership will be an example and a source of A visual tool has been developed to describe the key inspiration to others. concepts behind the proposed collaboration framework (Figure 4.1). This graphic was used in Agreement on these fundamental objectives, values several consultations. Generally, it has been well and principles will be an important step in moving the received by participants who felt it provided the “big collaboration framework forward. Reaching consensus picture” of what was being proposed. among the partners will be an important step in developing a more formal partnership agreement. In The graphic is a concept map or vision of collaboration addition, throughout the course of the partnership, that identifies a number of inter-related elements. these values, principles and objectives will continue These include: a) the environmental factors that form to be important because they will provide a foundation the context within which the collaboration will develop, for priority setting and the implementation of action b) the traditional and holistic First Nations and Métis plans. understandings about health that must inform the collaboration, c) the importance of shared vision, values and strategic plans to the collaboration, d) the desire to achieve excellence through capacity development in research, education and service A Conceptual Framework for delivery, and e) the expected positive outcomes and Collaboration benefits of collaboration.
Throughout the WTTE project, the importance of Throughout the consultations, many people asked how collaboration has been underscored. Collaboration is soon the collaboration proposal would bring strategic necessary for many reasons: to build solid and action on Aboriginal health issues. There is a sense of cooperative working relationships among the partners, urgency about the need to respond to poor health and to achieve better integration and coordination of social outcomes. While current efforts to improve services, to address the enormity of issues at hand, services should continue, the Collaboration such as poverty and marginalization, and to ensure Framework is meant to establish the necessary that the community’s foundation for partnered leadership. The framework
○○○○○○○○○○○○○○○○ voice is heard in establishes “why” and “how” we ought to work decision-making. Achieving excellence together to focus energies and create an opportunity for cooperative action in the future. Without such a Early in the project, the through collaboration, framework, the success of specific service project team advanced enhancement initiatives is likely to be quite limited. partnership, and shared the idea of developing a “centre of excellence” in In the graphic, three large ellipses in blue, gold and leadership should be Aboriginal health and green represent The Future, The Environment and healing. However, Collaboration. The blue ellipse represents a vision the focus of our efforts several advisors told us for the future. It is one that sees First Nations and that this term could Métis people maintaining and improving their health. connote comparison, The future well-being of the province, including all competition, and even elitism. Moreover, striving to residents, depends on the health and well-being of be known as the best could be mistaken for self-serving First Nations and Métis people. Moreover, as First image making, instead of action on important health Nations and Métis people attain improved health issues. Therefore, it was determined that the “centre status, they will make increasingly important for excellence” concept should be abandoned. Rather, contributions to the health and well-being of all people achieving excellence through collaboration, in Saskatchewan. In other words, the well-being of partnership, and shared leadership should be the focus the province and of First Nations and Métis peoples of our efforts. is inseparable.
54 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Figure 4.1 “Working Together Towards Excellence” Collaboration Framework
Serving all Residents of RQHR & Southern Saskatchewan . . .
Environment
Interdependent Autonomous Collaboration Determinants of Health Partnerships & Social Outcomes Shared Vision Joint Strategy & Values Obectives & Action Aboriginal Health Strength in Diversity Research Information, NATION PERSON Leverage Knowledge & Mental Affirm Emerging Challenges Strengths & Application & Opportunities Minimize Traditional Physical Spiritual Weakness Health Education, and Healing Emotional Excellence in Economic Conditions Employment, Health Care COMMUNITY FAMILY & Political Trends HR Build & Services Development System Develop Changes in Capacity Community Social Policy Develop Seek Funding Innovative & & Support Integrated Services
. . . With Emphasis on First Nations and Métis Citizens
Chapter 4: Towards Collaboration 55
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This inseparable link between the well-being of powerful ways. Sadly, we witness that faith Aboriginal people and of all people in Saskatchewan differences sometimes divide peoples and generate is brought home by the changing demography of the conflict, often with disturbing consequences. province. Increasingly, Aboriginal people will However within the proposed collaboration effort, contribute to the human, financial and other resources diversity is embraced as a source of strength. upon which the future prosperity of the province Differences are to be honored and we should look depends. This is an exciting opportunity to be to what is common to all, not to what may set us embraced. apart from one another;
The gold ellipse represents the current environment • Challenges And Opportunities where a number of opportunities and challenges are There are many challenges and opportunities in noted. These opportunities and challenges form the the current environment. Canadians are concerned context within which the proposed partnership will about the economy, the environment, government be developed. spending, the health care system, and many other issues. However, there is also increased awareness • Determinants Of Health about unacceptable First Nations and Métis health Broad social forces shape health and social and social conditions, and increased recognition outcomes. These include educational attainment, that many organizations must work together to employment, income, social supports, childhood make a difference. Each organization also faces its and family development, and many others. Thus, own challenges and opportunities. Working the collaboration cannot just focus on health together allows each organization, and the services. By working together, the collaboration collective, to better adapt to changing needs and framework provides a way to address these health opportunities; determinants and develop joint action plans for improving population health and wellness; • Political Trends and Economic Conditions Political and economic trends and conditions are • Diversity powerful influences on social policy. Fortunately, Diversity abounds in Canadian society and in governments at all levels have been paying much Saskatchewan. It is a strength to be recognized and more attention to policies affecting First Nations celebrated. There is diversity of beliefs, cultures, and Métis peoples. In addition, governments are lifestyles, political and religious convictions, increasingly recognizing that they must work leadership styles, and ways of understanding and together with First Nations and Métis peoples to reaching consensus on action. There is also build relationships that will deliver concrete benefits considerable diversity in the size and nature of at the community level. Insights and energies can service and political organizations, including their be combined to better achieve positive outcomes. missions, objectives, and action strategies. Working Economic realities are also important and may within such diversity is a challenge, but this affect the pace of change. However, if there is a approach promises an enhanced collective ability clear, workable plan, with obvious benefits, change to attain common objectives. By cultivating respect can occur. Improved productivity and effectiveness and goodwill through open communication, we can is always a priority for governments. In addition, align our efforts to respond more effectively to the First Nations and Métis governments and challenges before us. organizations are gaining autonomy and economic strength. Increasingly, they are making important For First Nations and Métis peoples and others, contributions, not only to their own peoples, but faith and prayer are fundamental to health and to the broader society as well. Even given many healing. Belief systems can move people in other priorities, First Nations and Métis health and
56 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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social policy issues are moving up on governments’ of centres of excellence: 1) research and knowledge lists of priorities; and management, 2) education and human resource development, and 3) service delivery (the yellow • Social Policy circles). Human resources development is felt to be Social environments are ever changing and social particularly important. First Nations and Métis human policies both respond to and precipitate such resources will be needed to develop and implement change. Improving collaboration will increase the joint action plans, and improving First Nations and ability of partners to understand, track and respond Métis education and employment is one of the most to emerging trends. The public, government important strategies for improving the health leaders, and senior administrators have become determinants that affect health outcomes. more supportive of major collaborative action to address longstanding social justice issues affecting Six blue circles identify some of the main benefits of First Nations and Métis peoples. Therefore, the collaboration. These provide a hoped for vision of timing for moving ahead with a new partnership is what can be accomplished if organizations work more ideal. collaboratively together.
The green ellipse sets out a number of the details of • Leverage Strengths the collaboration framework, including the Different partners and stakeholder organizations prerequisites that must be present for the partnership have different strengths and abilities. The to work (white circles), the proposed focus of the collaboration would allow for the strengths of each collaborative action (the yellow circles), and the partner to be identified and built upon. This is a outcomes that are expected from effective learning opportunity, an opportunity to support one collaboration (blue circles). another, and an opportunity to achieve synergies across organizations; The white circles identify some of the key prerequisites for working effectively together. While collaboration • Access Funding and Support is essential, it is also necessary to respect the By working together, partners can better keep independence and autonomy of each organization. abreast of funding opportunities, and align and Partners do not give up independence or autonomy realign themselves to support each other to take by deciding to work together. best advantage of changing opportunities. This can occur, for example, when organizations support A partnership also requires shared vision and values. one of the partners to obtain funding, or where These are the anchors that can be returned to time several organizations come together to submit a and again to insure that the partnership is working stronger proposal; effectively towards the common objectives that were established at the beginning. • Build Capacity The collaboration will support excellence by Partners also have to agree on what is important and developing new First Nations and Métis research, how they want to work together to achieve common human resources, and service delivery capacity; goals. In other words, there needs to be an agreed upon process for establishing joint objectives and joint • Develop Innovative and Integrated Services strategy. Bringing partners together creates opportunities for creativity and innovation to flourish in the The proposed collaboration for First Nations and development of new services, as well as in the Métis health and healing would focus on developing coordination and integration of existing services; capacity in three areas that reflect the best practices
Chapter 4: Towards Collaboration 57
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• Develop Community The holistic view of health challenges the “medical Health and human services are only part of a model,” as well as so-called “silo” approaches to response to health problems. By focusing on service delivery. These approaches are designed to deal building capacity, the collaboration will support and with specific needs, problems or symptoms of strengthen First Nations and Métis communities. sickness, often on a “one-client, one-problem-at-a- In the long run, this will have a significant impact time” basis. Such specific remedies, however helpful, on health outcomes; and are less likely to address the root causes of poor health and social outcomes. Placing the Medicine Wheel at • Affirm Traditional Healing the genesis of the collaboration recognizes the need The collaboration will seek to welcome, affirm and to rely upon holistic understandings and aspirations learn from First Nations and Métis Elders, as well that will bridge organizational mandates and overcome as community and government leaders. Knowledge approaches that compartmentalize services and about traditional healing will be incorporated into supports. all aspects of planning and service delivery, and this knowledge and experience will be used to guide the work of the partnership. Thus, the collaboration will affirm the world view and indigenous Who Should be Involved? knowledge of First Nations and Métis peoples, while respecting the spiritual beliefs, attitudes, As indicated in the previous chapter, and in the understandings and practices of other cultures and WTTE’s background paper on partnership groups. Collaboration is intended to be generous, opportunities, there are at least several dozen helpful, open and tolerant, as well as a learning organizations that could become involved in a experience and healing journey for all. partnership in a major initiative to improve First Nations and Métis health outcomes. These include At the beginning point of the graphic, a Medicine various levels of government, First Nations and Métis Wheel labeled “Aboriginal Health” appears. This is peoples, professional associations, community used to portray a holistic view of health. Its presence organizations, and many others. While all of these honors the importance of indigenous knowledge about organizations doubtless have an important role to play, health and wellness in the proposed collaboration. First a joint planning and decision making mechanism that Nations and Métis people told the WTTE team that is dependent on the involvement of all of them would health and wellness involves a balance of spiritual, likely prove to be quite unwieldy, frustrating and, in physical, mental and emotional aspects, and that it the end, ineffective. While information and input can requires harmonious and supportive relationships be gathered quite broadly, and while specific initiatives within families, communities and nations, throughout can be undertaken by any number of different the life cycle. groupings of organizations, a decision making forum that attempted to involve every conceivable partner The Medicine Wheel is placed in the centre or the would likely collapse under its own weight. core of the graphic, at the genesis of the collaboration framework, to signify the central importance of On the other hand, there are other considerations in indigenous ways of knowing, and to recognize these determining who and how many organizations should ways as a potent source of new thought, new be involved. Any forum that was not inclusive enough approaches, and new relationships. A rising sun to draw in key stakeholders would also fail. How could signifies that newness and promise of the joint action be undertaken without the involvement collaboration. Realizing the potential of the of key organizations in setting priorities and strategy? collaboration will take time; this is symbolized by the However administratively efficient such an approach passage of the Sun through the Medicine Wheel. might be, it would lack credibility. Decisions would
58 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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not be owned by those with key roles in designing and • Track Record implementing new initiatives. Does the organization have a track record of working successfully with other organizations to For these reasons, it is helpful to draw a distinction achieve common objectives? between “core partners,” partners whose involvement and support in decision making is necessary to achieve • Balance of Representation meaningful progress, and others who should also be Taken together, do the potential partners represent involved in bringing about meaningful change. A all the key constituencies that must be involved in realistic number of core partners is probably 12-15, order to make progress? Is there a balance of although a smaller number would probably be even representation such that the necessary ingredients better. to achieve excellence are present – organizations with service delivery , knowledge management, Some criteria for identifying “core partners” include: human resources, and research mandates and capacity? • Common Vision and Values Does the potential partner recognize the Core partners must make a significant difference in importance of improving First Nations and Métis the sustenance and success of the collaboration. health outcomes, believe there is an opportunity to achieve significant improvements, and want to In addition to the RQHR, other organizations that work together with other organizations to make a would appear to fit these criteria include: First Nations difference? governments, Métis governments, municipal governments, including the City of Regina and rural • Mandate municipalities, Saskatchewan Health, Saskatchewan Does the potential partner have a mandate that is Community Resources and Employment, the Public aligned with the common vision? and Separate School Boards, and post-secondary institutions, including the University of Regina. In • Resources and Capacity addition to these organizations, a number of Does the prospective partner have significant community leaders and Elders should also become resources and capacity (e.g., financial resources, involved. Participation from key professional groups, human resources, knowledge, relationships, such as physicians, would also have to be considered. credibility, etc.), and can some of these resources be used to achieve common goals and objectives? In some sectors, a number of organizations are potential partners. In the justice sector, for example, • Commitment the Regina Police, Saskatchewan Justice, Saskatchewan How committed is the potential partner to the Corrections and Public Safety, Federal Justice, Federal common vision? Is there commitment at the Solicitor General, the RCMP and the Corrections organizational level? Is there a commitment at a Services Canada are all potential core partners. In the personal level by at least one senior representative? post-secondary education sector, potential core Is there a champion of the collaborative effort? Is partners might include Saskatchewan Learning, SIAST, there a commitment to insure involvement and SIIT, SIFC, Gabriel Dumont, the U. of S., and the U. continuity over time? of R. In these instances, the organizations themselves might consider selecting one or two organizations to • Leadership represent the sector. They could keep the others Is the organization able to provide leadership to informed and involved as necessary. the collaborative process to help ensure the full potential of collaboration is realized? In some cases where there are local, regional, provincial
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and federal counterparts active in the same sector, a and resources, uncertainty or lack of trust concerning decision might have to be made about whether to the collaboration itself or some of the partners, and involve core partners from multiple levels, or whether the shear enormity and complexity of the challenge at to involve the regional or local body that best aligns hand. These potential obstacles can only be overcome with the purpose of the collaboration and the in time, by being clear about objectives and mandates of the other partners. For example, local expectations, by closely adhering to the purpose of school boards might be able to bring more direct the collaboration, and by monitoring and knowledge, expertise and resources than provincial demonstrating concrete results. or federal agencies with an education mandate. Decisions will also have to be made about the level The accompanying graphic provides a pictorial and type of representation, particularly for large representation of the proposed core partners (Figure organizations with complex organizational structures. 4.2). It should be noted that there is no attempt to Such organizations will likely want to have equivalent weight the representation of potential partners. For representation, that is, representation that roughly example, in order to reflect an appropriate level of corresponds to the rank and authority of involvement, it may well be necessary to have a number representatives from the other organizations. of representatives from First Nations and Métis governments to insure an appropriate balance of A senior level of representation will likely prove to be representation with other organizations and levels of most effective, because collaboration is intended to government. lead to joint decisions and joint action. Organizational buy-in and ownership is critical to developing these The selection process would have to overcome a joint plans and action strategies. Problems could occur number of potential pitfalls – the difficulty of if individuals who have little or no decision making maintaining continuity and commitment, the authority become involved. If this were to occur, more reluctance to share power and resources, jurisdictional junior representatives might have to be continually issues, recent historical issues (baggage), limits on time checking back for approval from their organizations.
Figure 4.2 Proposed “Core Partners” in the Collaboration Framework
First Nations Mtisé - Treaty 4 -Mé tis Nation Provincial - Social Services Education - Health -School Boards
Community Federal - Leaders - FNIHB - Elders - INAC Justice -Justice -Police
Municipal Post- - Urban Secondary - Rural Health - U of R - RHA #4 - Other
60 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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There is a danger the forum could evolve into one The development of the partnership agreement should that focuses on information sharing, rather than one follow the established protocol within each that focuses on priority setting, decision making, and organization. Each organization has its own processes the allocation of resources. The whole process could for consulting, for involving the appropriate levels of get bogged down very quickly, and lead to leadership, for seeking approval, and for committing disenchantment and frustration for all concerned. resources. These protocols will have to be understood and respected as the partnership agreement is being What about other partners? Their involvement is also developed. essential. Community organizations, various departments of government and other agencies would Once the partnership is formally established, it is need to have the opportunity to bring issues to the anticipated that senior leaders from the partner
table, and they would need to have an opportunity to organizations will come ○○○○○○○○○ develop and implement specific initiatives in together on a regular ○○○○○○○○ conjunction with others. Any number of committees, basis to develop Partners would take task forces, working groups and research projects priorities and mandate could be established to insure all of the key groups action. Initially, this collective responsibility are involved in addressing the priority issues that are might involve identified. commissioning for establishing the research or developing Core partners will need the assistance and support of objectives and expected proposals to address many other organizations. One of their responsibilities priority needs. Later, outcomes for each joint should be to insure the involvement of others. For activities would shift to example, core partners can help overcome barriers and considering project obtain needed resources so that other organizations recommendations that can become more meaningfully involved in the plan come back to the of action. collaboration. At this point, implementation of recommendations, including resource implications, would need to be discussed and agreed upon. Initially, the partners would likely wish to focus on areas where How will the Partners Work Together? “early successes” are possible. In particular, there are a number of opportunities for linking, coordinating Before collaborative work on specific initiatives can and improving existing services. Action on some of begin, it is likely that some effort will be required to these opportunities may require little or no additional formalize the partnership. A written partnership financial resources, although they could require agreement is contemplated. This would set out the significant changes in the way the partners work common mission, as well as the shared values and together. principles that would be the foundation for working together. The agreement might also speak to The partners would take collective responsibility for expectations and commitments. Commitments might establishing the objectives and expected outcomes for include such things as the commitment to be involved, each joint project. The partners would enable action perhaps for a fixed term, the commitment to champion by mandating the involvement and support of their the partnership with the public and within host organizations. Joint, interlocking priorities and work organizations, the commitment to provide continuity, plans would need to be developed. As required, for example, by undertaking to orient and mentor new existing resources could be realigned, or new resources representatives if they become involved, and the could be sought out. Together, the partners would commitment to provide resources. monitor progress towards established goals, evaluate
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outcomes, and take any corrective actions that were therefore, it will be necessary to coordinate plans and needed. Some or all of the core partners, as well as activities with these other groups. agency and community representatives, could become involved in specific projects, depending on the nature Once the Collaboration Framework is developed, it of the project. should act as a resource to these and other community planning processes. With regard to the Drug Strategy, The partnership will require resources to review and for example, this is not an Aboriginal-specific initiative, support generic strategies that are aimed at providing although it has obvious implications for improving health services and social supports to the community. services for First Nations and Métis people. Had the However, resources and expertise will also be required Collaboration Framework been in place, those involved to insure that these generic strategies are effectively in the Drug Strategy might have brought forward their adapted to ideas as a way of insuring that First Nations and Métis
address the perspectives and concerns were adequately reflected ○○○○○ ○○○○○○○○○○○○○○○○ needs and in the plans, methodologies and recommendations. The Collaboration Framework priorities of Member organizations could have offered their advice, Aboriginal expertise and resources to help carry out the project. would have an important role people. Core And the endorsement of the Collaboration Framework in pro-actively identifying partners and would no doubt have assisted in the successful others who need completion of the project. planning and service priorities, to be involved will require the However, the Collaboration Framework would also and in finding the necessary support of the have an important role in pro-actively identifying partnership to planning and service priorities, and in finding the resources and partners for move forward in necessary resources and partners for carrying out these carrying out these activities implementing activities. In some instances, these activities might be agreed upon carried out in cooperation with existing inter-agency actions. or inter-sectoral forums, such as those mentioned above. Indeed, the Collaboration partners would no The partnership would be responsible to the doubt wish to influence the priorities of these other community and to the individual partner organizations. groups. In other instances, the activities might be The partnership would take collective responsibility carried out by one or more of the Collaboration for celebrating successes, providing information to the Framework partners, or with resources that the public, and accounting to the community and to the partners have pooled to support joint initiatives. In partners organizations. each instance, the partners would have the opportunity to make decisions about the best way of proceeding. Quite a number of inter-agency and inter-sectoral forums and projects already exist in Regina and within the region. These include, for example, the Youth Justice Forum, the Inner City Initiative, Kids First, What Issues will the Collaboration the Drug Strategy, the United Way’s community Address? planning process, and the Regina Inter-Sectoral Committee. None of these forums is a substitute for The number and range of issues that could be the Collaboration Framework, as none attempt to bring addressed by the collaboration is overwhelming. Thus, decision makers together to focus specifically on First in order for the collaboration to maintain its purpose Nations and Métis health issues. Nonetheless, there and focus over time, some thought will have to be are many common interests and concerns and, given to terms of reference for determining
62 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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appropriate agenda items for collaborative work. How • Addressing the need for Aboriginal human should the partners determine what makes it on to resources development; the agenda and what does not? Such decisions would have to be made keeping in mind the unique role and • Developing support services for children, youth purpose of the collaboration. Flexibility will also be and families at risk; required, because the partnership will change and adapt as new challenges are addressed and as new • Developing public awareness and support services opportunities become available. for health promotion, illness prevention, and positive personal health practices; Some criteria that might be used to identify suitable issues for consideration are as follows: • Incorporating culture and spirituality into program development and service delivery across sectors; • The issue has the potential to significantly impact First Nations and Métis health outcomes; • Identifying and prioritizing significant service gaps; and • The issue crosses mandates and responsibilities of a number of sectors and partners, it does not fit • Improving coordination among various agencies, neatly into the responsibilities of one or more communities and levels of government. existing partners; Early in its development, the collaborating partners • The results are achievable in a reasonable time would need to agree on a process for the initial frame; establishment of a reasonable number of priorities. • The issue is identified by partners and the community as significant;
• There is potential to develop innovative solutions; Resources
• There are opportunities to realign existing Supporting the collaboration framework and initiating resources, access new resources, or create synergies action on agreed upon priorities will require resources. among the partners; Some of these resource implications cannot be anticipated with any certainty, because a common • There is potential to achieve excellence by creating action plan has not yet been developed by the partners. new knowledge, improving services, and Nonetheless, agreement on several key principles developing Aboriginal human resources capacity; would advance the collaboration framework. Some of these principles include: • Dealing with the issue successfully will help to build the partnership. • All partners should commit to providing resources to support the collaboration; What issues would meet these criteria? Of course, there are many candidates. One of the early tasks of • It should be recognized that the contributions from the partners should be to develop a consensus about each organization will be different, in terms of both their agenda for future collaborative work. However, quantum and type. However, all would be some possible areas may be mentioned: considered of equal value – financial resources, human resources, credibility, social capital, • Addressing poverty, unemployment and other knowledge, etc. determinants of health;
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• Partners should be prepared to commit resources functions on behalf of the partnership. Alternatively, that are commensurate with the scope and partners could divide responsibilities among responsibilities of their organizations; themselves. Another option is to create a new organization to provide these functions. To avoid a • Partners should commit to use their best efforts to situation where the partnership stalls, the partners will follow through and implement the resource have to make some reasonable provisions to insure decisions that are jointly arrived at. that these needs are addressed.
Without these commitments, it is unlikely partners would own or be committed to a common agenda. In these circumstances, the partnership could quickly Implementing the Collaboration break down. Framework
In addition to the resources for specific initiatives, it The Next Steps is clear that the collaborative framework itself will require support. A number of core functions will have Although there has already been considerable progress to be performed initially, and on an ongoing basis. in continuing to build productive working relationships These include: calling meetings, preparing background with the core partners who would become part of the documents, Collaboration Framework, additional steps are needed
○○○○○○○○○○○○○○○○○○ preparing and to build consensus and formalize agreements. Getting the collaboration framework off the ground and Steps will have to be taken circulating minutes, public running smoothly will require a commitment from all to insure that traditional communications on of the organizations who agree to become involved. behalf of the However, someone has to take the lead. First Nations and Métis partnership, coordinating Over the past year, the RQHR has taken considerable beliefs and values are activities of various initiative in reviewing literature, developing ideas, and consulting with others. Now that this work has been incorporated into the working groups, providing support to completed, the RQHR must play a different role — partnership’s planning and working groups, one of an equal partner in a broad-based coalition of monitoring the work organizations committed to improving First Nations decision making processes of committees, and and Métis health outcomes. evaluating the effectiveness of the The results of the WTTE project should be taken partnership itself. The partners will need support it forward to the proposed core partners and core can rely upon for assistance in these areas. partners should be invited to be a part of the Collaboration Framework. RQHR’s support will be There will be other resource needs. The capacity to required through the consultation process that will lead support planning and evaluation will be key. In to agreement on principles and priorities. Since the addition, specific steps will have to be taken to insure collaboration framework is intended to be a decision that traditional First Nations and Métis beliefs and making forum, it must involve senior representatives values are incorporated into the partnership’s planning from the partner organizations. Therefore, the RQHR and decision making processes. will also have to commit senior management resources to carry out these responsibilities. Several options for addressing these requirements can be considered. One organization could host these Other core partners will have their own ideas about
64 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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principles, values and priorities, and maybe even about 3. Maintaining current and complete information what sort of agreement is required. For some of the about programs and services related to Aboriginal organizations who wish to become involved, a lengthy health, and making this information available to approval process may be required before a formal managers, boards, the public, and interested agreement can be executed. There will be lots of stakeholders. This would include raising awareness questions, lots of concerns, and lots of ideas. All of within and outside the partner organizations about the partners will have to be patient and flexible, as the commitments and accomplishments related to First process could take a number of months to complete. Nations and Métis health, for example, making However, taking this time should be regarded as an presentations to internal and external groups, important investment that will reap rich rewards in attending key conferences, and maintaining on- heightened trust, cooperation, and effectiveness. going communication with key Aboriginal and non- Aboriginal government representatives; It is important to maintain the considerable momentum that has been built up over the last year. 4. Liaison and coordination with external Therefore, the RQHR and the other core partners stakeholders. This would include networking with should establish some ambitious time lines for moving government and non-government representatives, forward. representatives from other levels of government (municipal, federal, provincial), and representatives Budgetary Considerations from other organizations (e.g., universities) who are not core members of the collaboration The Collaboration Framework will require staff framework; support to work effectively. Initially, this support will be needed to organize meetings, maintain records, 5. Serving as a high profile point of first contact follow-up on decisions, and keep the process moving. for internal and external stakeholders on a wide Support will also be required on an on-going basis for variety of issues related to First Nations and Métis these same purposes. If this support is not provided health. This would involve networking, dialoguing through dedicated staff resources, progress will be and maintaining on-going communication with slow, frustration will set in, and the whole initiative these and other key groups; may falter. 6. Developing joint projects and strategies with Specific functions that will need to be performed internal and external stakeholders to promote include the following: collaboration and improve health outcomes. Current information about funding opportunities 1. The planning, coordination and evaluation of would be maintained and assistance in developing First Nations and Métis health services, including, proposals and strategies would be provided;. for example: developing annual plans, goals, and expected outcomes, preparing proposals for new 7. Providing analysis and advice to senior services, evaluating existing services, preparing management and the Boards of partner annual reports and other reviews that describe organizations with respect to Aboriginal health services and the outcomes being attained; policy and service issues;
2. Providing support to managers within the RQHR 8. Enabling the core partners and other partners and other partner organizations in their strategic to improve the cultural appropriateness, quality and and operational planning. This might include effectiveness of services by removing barriers, participating in strategic planning initiatives, accessing new resources, and linking organizations evaluation initiatives, accreditation reviews, service together so that they can better draw on each others quality audits, etc.; strength and capacities;
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9. Providing a secretariat-type function to the From a practical standpoint, RQHR may have to Collaboration Framework, Advisory and Elders provide most of the resources to get the process groups, and other working groups that are moving forward. Therefore, it is recommended that established by the partnership. This would insure RQHR assume all of the financial responsibility in the development and implementation of year one, and aim to carry half the financial appropriate action plans, coordination of efforts, responsibility in future years. As the initiative develops, and timely reporting to member organizations; there should be an expectation that other partners will also contribute financially. For planning purposes, it 10.Representing the partners in a wide variety of is reasonable to expect that 50% of the financial external forums where First Nations and Métis resources (five partners each covering 10%, or some health and social issues are being addressed; and similar configuration) could be contributed by other partners. 11.Generally serving as a point of information, referral, contact, communication and support In order to effectively discharge the responsibilities for Aboriginal health issues within the region. that have been enumerated, a director, two analysts and a support staff position are deemed to be While any of the partner organizations could dedicate necessary. The budget should also take account of resources to address these functions within their own the need to have some flexible contract dollars available organization, it is recommended that resources from to address specific program development, proposal member organizations be pooled so that these development, planning and program evaluation needs. functions can be jointly carried out on behalf of all An annualized budget of about $400,000 would be the members. In this way, resources are shared, required, however, the budget in the first year would cooperation is encouraged, support is available to all approximate $150,000. of the member organizations, and there is a minimum of duplication across organizations.
The support of the Collaboration Collaboration Framework Framework should be regarded as a Budget RQHR Share Other Partners Total joint responsibility of the collaborating partners from the beginning. 2003-2004 $150,000 $ - $150,000 Therefore, other organizations should 2004-2005 $200,000 $200,000 $400,000 be invited to consider providing 2005-2006 $200,000 $200,000 $400,000 financial support. In addition, decisions will have to be made about how to establish RQHR will also need some financial flexibility to the support function. As previously discussed, there participate in new initiatives that are agreed upon by are a number of options: 1) establishing support within the Collaboration Framework partners. Some of this one of the core partners, 2) establishing support in a work can proceed on the basis of existing, realigned number of core partners, as a type of virtual support resources. Some can proceed with resources from system, or 3) creating a new organization. other partners. Some can proceed with new resources Other sources of funding, such as the Primary Health that the partners access together. However, it is also Care Transition Fund, may be available to provide highly likely that seed money will be required for some some financial support. As discussed in Chapter 5, new initiatives, particularly early on. Having such steps are already underway to prepare and submit a resources available will also greatly increase the $2m, three year funding proposal to this Fund. chances of securing commitments from other partners. However, since the Collaboration Framework is In addition, in the current environment, obtaining new intended to be a permanent and ongoing initiative, resources (e.g., federal grants) often requires that time limited funding should be used with caution. applicants put up some of the required funding themselves. For all of these reasons, the availability
66 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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of some “seed funding” will be necessary to insure outcomes. It calls on partners to work together in new the success of the partnership. ways, by pooling strengths, commitments and resources. The establishment of an Aboriginal Health Initiatives Fund is proposed. While RQHR would provide all of The proposed Collaboration Framework will take time the seed funding in the first year, there would be an to develop. Potential partners will bring their own ideas, expectation that the fund would grow to a significant and these will have to be incorporated into the amount over time, and that partners would share in proposed model. Further discussions will be required, the financial responsibility. As with the core funding and the process of continuing to build trust will take for the Collaboration Framework itself, it is suggested time. that other partners might contribute 50% of costs, starting in year two. The proposed strategy will also require new resources, both for the development of the collaboration framework itself, and Aboriginal Health Initiatives Fund also for the funding of new First Nations and Métis health initiatives Budget RQHR Share Other Partners Total that are decided upon by the partners 2003-2004 $ 50,000 $ - $ 50,000 to the initiative. 2004-2005 $150,000 $150,000 $300,000 2005-2006 $250,000 $250,000 $500,000 However, there is widespread recognition that past approaches to planning and decision making have The establishment of an Aboriginal Health Initiatives not always been effective, and there is a willingness to Fund would create an important precedent, since it entertain new ideas and new approaches. If partners would allow for the pooling of funds across are willing to dedicate themselves to working across organizations. These funds would be used for jointly boundaries, and if these efforts are grounded in First determined priorities. Provided there are early Nations and Métis values and approaches, there is successes, such a fund could grow to include significant every reason to believe that significant progress is pooled funds for Aboriginal health and possible. healing initiatives. To underscore the principles involved, the RQHR may even Collaborative Framework and Aboriginal Health wish to consider making its contribution Initiatives Fund contingent on the commitment of matching funds from some of the other Budget RQHR Share Other Partners Total partners in the Collaboration 2003-2004 $200,000 $ - $200,000 Framework. 2004-2005 $350,000 $350,000 $700,000 2005-2006 $450,000 $450,000 $900,000
By pursuing a collaborative approach, the RQHR and Conclusion its partners have the opportunity to provide the leadership in an area of critical importance to the Building on the background research and consultations region. This leadership can go a long way in insuring carried out during the WTTE project, this chapter that incremental and already available resources are has outlined a bold vision for the future. It involves a used in ways that have the most beneficial impact on concrete strategy for building a framework for joint the health of First Nations and Métis peoples. planning and joint action that will bring together key partners to improve First Nations and Métis health
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68 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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CHAPTER 5 The Aboriginal Health Initiative, an extensive, two year research, planning and consultation process initiated by the former Regina Health District, identified a number of priority areas for improving health services Enhancing for First Nations and Métis people. During the course of the WTTE project, there was an opportunity to confirm the importance of these priorities and to RQHR’s develop specific ideas about the best strategies for addressing current gaps and needs. In addition, the Aboriginal Health Initiative Internal Working Group Capacity has continued to meet. The members of this Group provided leadership in the development of specific plans to implement the AHI’s recommendations. As The previous chapter outlined a framework for joint a result of this significant work, it is now possible to planning, joint decision making and joint action with identify a number of specific and complimentary key organizations that share concerns about First recommendations for the consideration of senior Nations and Métis health outcomes. The proposal to management and the RQRHA. establish a “collaborative framework” reflects the fact that improving Aboriginal health outcomes requires Extensive research and consultations indicates that action on broad social, economic, cultural and other there are a number of opportunities for the RQHR to “determinants of health” over which any one improve health promotion programs for First Nations organization has quite limited control. Thus, and Métis infants, children and families. These efforts collaboration with other organizations, including First should focus on infant and child development and the Nations, Métis, municipal, provincial and federal strengthening of Aboriginal families. Specific priorities governments, as well as many other organizations, is for action discussed in this Chapter include: infant essential if meaningful progress is to be made. mortality, breast feeding, the reduction of hospital admissions of First Nations and Métis children and While the Collaboration Framework is being youth, continuity of care for First Nations and Métis developed, and even after it begins to address the broad newborns and their families, infant and child and complex social and economic issues that influence development, food security, teen pregnancy and youth health outcomes, there will continue to be a need for sexuality, diabetes, and dental health. all human service organizations, including the RQHR, to examine how the cultural appropriateness, quality While there are many other needs and opportunities and effectiveness of services can be improved. This that have been identified by various internal and second strategic direction is discussed in this Chapter. external stakeholders, those mentioned above require priority attention for several reasons. These are the Based on the continuing work of the Aboriginal Health areas where the most serious inequities exist for Initiative Internal Working Group, a number of Aboriginal people. They are also the areas where there opportunities to improve RQHR’s health services for are opportunities to prevent serious health problems First Nations and Métis people have been identified. down the road. Furthermore, a good deal of In addition to these service improvements, there is a information is already available about effective health need to increase the RQHR’s capacity to plan and promotion strategies in these areas and, therefore, there coordinate its First Nations and Métis health initiatives. is the very real prospect of having a significant impact This second strategic direction, therefore, focuses on over a reasonable time frame. how the RQHR should go about significantly enhancing its organizational capacity to address First Later in this Chapter, a number of other important Nations and Métis health issues.
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priorities are discussed. These address the need to of incidence data, and development of evidence-based improve home care services, mental health and practices are required to support effective planning, addictions services, culture and spirituality programs, evaluation and continuous service improvement. In and the region’s education, employment and training addition, service enhancements are needed to meet programming in support of First Nations and Métis the high volumes being addressed by the two current health initiatives. high risk prenatal programs — Healthiest Babies Possible and Baby’s Best Start. Generally then, more information is required. Specific plans then need to be taken forward to the Collaboration Framework partners for discussion and decisions about joint Infant Mortality action.
Background Specific actions being proposed include:
Research conducted for the Aboriginal Health • Decrease infant mortality in the Aboriginal Initiative indicates that approximately 11% of live population births in Saskatchewan are to women under the age Population and Public Health Services would of 20. Among registered Indians, it is approximately review the current literature, epidemiology and 25%. Teenage pregnancy is linked to increased health known risk factors. Based on these findings, a risks, including complication of pregnancy, low birth proposed plan of action would be taken forward weight, premature birth, infant mortality, and other to the Collaboration Framework partners; negative health outcomes. The infant mortality rate per 1,000 population was 8.3 in 1997 for the general • Increase access to holistic, culturally Saskatchewan population, and 19.3 for registered appropriate prenatal care Indians. This would involve: 1) addressing barriers to care through a) hiring a researcher to conduct a baseline Information gathered from service providers indicates study and community research to determine the that intravenous drug use among young Aboriginal numbers being missed by current services, as well mothers is an increasing concern. This group is also as barriers to care, b) developing a comprehensive more likely to go without proper prenatal care. Staff strategy to improve access for higher risk clients of Healthiest Babies Possible and Baby’s Best Start to Healthiest Babies Possible and Baby’s Best Start, believe that current programs are not being used by and c) improving linkages with family physicians the highest need population and that birth outcomes to increase access to pre- and post-natal care, 2) could be improved if clients could be seen earlier in Increasing outreach activities through a) increasing their pregnancy. Thus, there are opportunities to the delivery of services through agencies and identify barriers to services, and to enhance prenatal service providers who already have an established services, including addictions counseling, so that an working relationship with high risk clients (Street increased number of at-risk young moms receive the Project staff, Carmichael Outreach, etc.), and b) services they need. providing more support, education, and linkages through Healthiest Babies Possible, and 3) Proposed Plan of Action increasing the capacity of Healthiest Babies Possible and Baby’s Best Start to meet increased There is a need for a comprehensive approach to demands for service; reduce infant mortality and increase the number of healthy births in the Aboriginal population. Prenatal • Improve access to mental health and and addictions services need to be integrated into an addictions services overall plan. Targeted population research, compilation This would involve: 1) improving pre-natal care in
70 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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conjunction with Kids First, 2) working with region-wide plans to reduce these rates, would Mental Health Services to increase the availability require one time costs of $50,000; of client centered, holistic counseling for pregnant moms, 3) improving access to client and family • Increasing capacity in the Healthiest Babies centered holistic addiction services as part of the Possible and Baby’s Best Start programs through Drug Strategy, and 4) linking with the broader the addition of two community health workers strategy to reduce infant mortality; would require annual costs of $80,000 (50% in the first year). • Reduce reliance on hospital admissions of pregnant Aboriginal women This would involve: 1) developing a Infant Mortality comprehensive strategy to achieve reduced admissions, starting with a Budget RQHR Share Other Partners Total review of admissions and discharge 2003-2004 $128,000 $ - $128,000 data and the completion of research 2004-2005 $ 80,000 $ - $ 80,000 to better understand how to 2005-2006 $ 80,000 $ - $ 80,000 overcome barriers to existing community services, and 2) strengthening linkages Expected Outcomes in the continuum of pre- and post-natal care, and developing closer linkages with community health The specific outcomes that will be achieved as a result workers in Aboriginal communities to improve of these initiatives include: discharge planning, client support, and follow-up; • The development of an evidence-based, region- • Holistic hospital care wide plan to address the incidence of infant This would involve developing better linkages to mortality; community services to deal more holistically with the issues facing clients, and 2) realigning existing • A 15% increase in the number of high risk, prenatal RQHR resources to provide better follow-up and clients served by Healthiest Babies Possible and support to clients after leaving the hospital. Baby’s Best Start;
Resource Requirements • The development of community-based outreach services for the high risk prenatal population that Resource requirements related to preventing infant are delivered through community agencies but mortality include: linked to existing RQHR programs; • • Establishing baseline data regarding the number Improved access of high risk pre- and post-natal clients to mental health and addictions services; of prenatal clients not being reached and the barriers to care. This would require one time costs • A reduction in the number of hospital admissions of $38,000; of pregnant Aboriginal women; and • Compiling existing information about the current • Improved coordination of services across a literature, epidemiology, and common risk factors associated with infant mortality in the region, and continuum of care for pre- and post-natal clients. establishing and supporting a task force to develop
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Breast Feeding Expected Outcomes
Background This initiative will lead to an increase in the rates of sustained breast feeding among Aboriginal mothers The World Health Organization recommends breast followed-up by the Healthiest Babies Possible and feeding continue until a child is two years of age, Baby’s Best Start programs. however, the incidence of sustained breast feeding among new Aboriginal mothers followed by the Healthiest Babies Possible and Baby’s Best Start Programs is low. The initiation rate for Healthiest Babies Possible is 78%, but between three and six Hospital Admission of First Nations and months, it drops to 38%. Only 9% of mothers breast Métis Infants and Children feed beyond 6 months. There is a need to more clearly understand the barriers to breast feeding for low Background income populations so that effective strategies can be developed. There is also a need to establish baseline Hospital admission rates for Aboriginal infants and rates so that the effectiveness of programming can be youth are much higher than for the general population, better monitored and improved. especially for respiratory and gastrointestinal reasons. These observations have been confirmed in research conducted for the Aboriginal Health Initiative. Proposed Plan of Action Improved outreach programs to strengthen the care provided by Aboriginal families at risk will be required With regard to breast feeding, the first step is to to address this problem. confirm baseline information and to more fully understand the barriers to breast feeding for low Proposed Plan of Action income populations. Specific strategies to increase rates of sustained breast feeding among mothers participating in the Healthiest Babies Possible and A number of strategies and tasks are proposed in Baby’s Best Start programs can then be developed and conjunction with the pre-natal services available discussed with the Collaboration Framework partners. through Kids First. These include: 1) establishing baseline admission and discharge data, 2) utilizing social workers, Native Health Services, and Public Resource Requirements Health Nurses to provide follow-up and support to at risk clients after discharge from the hospital, 3) having With respect to increasing breast feeding among the Mother Baby Unit, the Maternal Visiting Program Aboriginal mothers, the establishment of a six month and Public Health Nursing develop stronger links with term position to enhance research and planning service providers on reserves and in surrounding capacity is proposed. This would involve one time communities, 4) exploring ways to provide more costs of $38,500. developmental follow-up for addicted babies, and 5) providing more follow up of high needs babies to provide support and monitoring of oxygen, tube feeds, medical needs. Breast Feeding Resource Requirements Budget RQHR Share Other Partners Total 2003-2004 $ 38,500 $ - $ 38,500 The action plan respecting the 2004-2005 $ - $ - $ - reduction of hospital admissions can 2005-2006 $ - $ - $ - be carried out with existing resources.
72 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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staff to shadow social workers, public Reduce Hospital Admission health nurses and other community- Budget RQHR Share Other Partners Total based staff so that they can develop a 2003-2004 $ - $ - $ - better understanding of issues from 2004-2005 $ - $ - $ - clients’ perspectives, 3) providing 2005-2006 $ - $ - $ - cultural awareness training for staff, 4) creating opportunities for staff to Expected Outcomes listen to women’s stories and experiences of hospitalization, and 5) exploring ways As a result of this initiative, there will be a decrease in of using social workers, Native Health Services, Kids hospital admissions for Aboriginal infants and children. First, and Public Health Services to provide support and follow-up to clients after they have left the hospital.
At least for the foreseeable future, it will not be possible to insure that Aboriginal staff are available in all Continuity of Care for First Nations and programs at all times when Aboriginal people are Métis Newborns and Their Families receiving services. However, by drawing on Aboriginal staff from key RQHR programs, such as Native Health Background Services and the Representative Workforce Program, it is possible to train and support staff throughout the Some 65% of the moms served by the Mother Baby region so that they are better able to offer appropriate Unit are Aboriginal, and some 50% of babies cared and effective care. for in NICU are Aboriginal. A more culturally sensitive service would allow staff to provide better care and Resource Requirements supports for Aboriginal families. Aboriginal moms should receive holistic and culturally sensitive care Improving cultural sensitivity and continuity of care from the Mother Baby Unit and in the NICU. for Aboriginal infants and families will require Moreover, coordinated follow-up services are required replacement costs for nursing staff in the NICU and in the community following discharge from the Mother Baby Unit to participate in cross cultural hospital. learning activities. This would involve $20,000 per year for two-years. On-going activities could then be funded Proposed Plan of Action through existing budgets. Additional resources of $100,000 is required to support Native Health Services A comprehensive and integrated strategy to strengthen taking a more proactive role in education and support. Aboriginal families needs to be developed. This should be pursued with RQHR’s partners in the Collaboration Aboriginal Infants and Families Framework. Budget RQHR Share Other Partners Total 2003-2004 $ 70,000 $ - $ 70,000 Specific actions with respect to 2004-2005 $120,000 $ - $120,000 improving continuity of care for First 2005-2006 $120,000 $ - $120,000 Nations and Métis newborns and their families involves developing a strategy to increase culturally appropriate services provided by Expected Outcomes the Mother Baby Unit and the NICU. This involves: 1) increasing staffing resources in Native Health This initiative will improve cultural sensitivity and Services so that they can train and support staff in continuity of care for Aboriginal infants and families. these units, 2) providing opportunities for hospital
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Healthy Infant and Child Development Resource Requirements
Background Funding is required to hire an additional public health nurse in the Sunrise Health Program at the Four Two issues have been identified that seriously threaten Directions Community Health Centre. Costs of salary healthy infant and child development in a number of and benefits would be $70,000 (50% in the first year). Aboriginal families. The first relates to the high incidence of diabetes among pregnant Aboriginal moms, and the Healthy Infant and Child Development second relates to alcohol and drug abuse among pregnant Aboriginal moms. Budget RQHR Share Other Partners Total Addressing these issues will significantly 2003-2004 $35,000 $ - $50,000 improve health outcomes for Aboriginal 2004-2005 $70,000 $ - $70,000 infants and children. 2005-2006 $70,000 $ - $70,000
Aboriginal women have 5 times the rate of diabetes Expected Outcomes compared to women in the general population. High rates of diabetes among women of child bearing age Outcomes of this initiative include the completion of is of particular concern because of the risk of the proposed initiative, and the enhancement of gestational diabetes. programs offered through the Four Directions Community Health Centre. These programs will There are no reliable numbers regarding newborns reduce the risk-taking behavior among Aboriginal affected by maternal use of alcohol and other drugs women and lead to better health outcomes for during pregnancy, but considerable anecdotal evidence Aboriginal infants and children. indicates the rates for Aboriginal women are high. In one survey, for example, the estimated rate of FAS and possible alcohol–related effects was 46 per 1,000 among Aboriginal children in the Yukon, and 25 per 1000 in British Columbia. RQHR staff have also Food Security observed high rates of FAS, FAE and other substance abuse problems among Aboriginal women. Background
Proposed Plan of Action Aboriginal citizens consulted during the Aboriginal Health Initiative expressed grave concerns about the Suggested actions include: poor nutritional status of Aboriginal people within the region. Due to poverty, many families, especially • Public Health Services will work with Information those in North Central Regina, do not have enough Technology and the Collaboration Framework money to cover the cost of their basic needs. There partners to complete an inventory of initiatives that are no supermarkets in the area. Lack of transportation are aimed at reducing drug affects among is a barrier to many; they don’t have a car to travel to Aboriginal babies; and the larger food stores where they can take advantage of lower produce prices. Existing food security • Working with the Collaboration Framework programs, such as the Food Bank, community partners, RQHR will develop an enhanced capacity kitchens, and the Good Food Box are available, but to deliver programs at the Four Directions they are not adequate to meet current needs. Starting Community Health Centre to address gestational in North Central Regina, improved strategies are diabetes, FAS/FAE, and substance abuse.
74 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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needed to help Aboriginal families access adequate significantly higher than for the general population. food. For example, the chlamydia infection rate in the 15 to 19 age group was five times higher in the registered Proposed Plan of Action Indian population than in the general population, while the rate of gonorrhea was approximately 18 times The proposed plan of action with respect to food higher. Reducing the incidence of teen pregnancy, as security involves working in collaboration with other well as the incidence of STDs, should be a priority partners to review existing food security initiatives, to for Aboriginal health promotion programs. identify gaps and to establish an action plan. The intent is to begin in areas of highest need, such as North Proposed Plan of Action Central Regina. With respect to teen pregnancy and sexually Resource Requirements transmitted diseases, the proposed plan of action includes developing a comprehensive primary RQHR’s contribution towards the improvement of prevention program aimed at intersectoral food security programs would involve expanding the collaboration, health education, healthy public policy, Four Directions nutritionist position. This would community development, social marketing, and self- involve annual costs of $12,000. help. Specific initiatives would include: 1) building on the Aboriginal sexual health needs assessment conducted by the Regina Food Security Sexual Health Coalition, 2) working Budget RQHR Share Other Partners Total with the Regina Sexual Health 2003-2004 $12,000 $ - $12,000 Coalition and the Boards of 2004-2005 $12,000 $ - $12,000 Education to support the curriculum 2005-2006 $12,000 $ - $12,000 related to sexual health and wellness for youth in high school, 3) increasing the skills of Public Health Nurses to Expected Outcomes partner with teachers in providing sexuality education, and 4) increasing outreach services through Four As a result of this initiative, a food security plan will Directions Community Health Centre, Primary Health be developed and implemented, beginning with North Care Nurses and community agencies, such as Central Regina. Carmichael Outreach.
Resource Requirements
With respect to the prevention of teen pregnancy and Teen Pregnancy and Sexuality sexually transmitted diseases, $12,000.00 is required to support the development of a comprehensive Background primary prevention plan. Further resources will be In 1997, the fertility rate for women aged 15 to 19 was 110 per 1000 for registered Indians in the province and 37 for the Teenage Pregnancy and Sexuality general population. For the registered Budget RQHR Share Other Partners Total Indian population within the former 2003-2004 $12,000 $ - $12,000 RHD and its service areas, the incidence 2004-2005 $ - $ - $ - of genital chlamydia and gonorrhea is 2005-2006 $ - $ - $ -
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needed to implement the plan. The identification of Saskatchewan Health originally provided pilot funding resource requirements to support implementation will for this project which has successfully demonstrated be part of the primary prevention plan. the value of intersectoral approaches to the primary prevention of Type II diabetes in North Central Expected Outcomes Regina, 4) developing a Type II diabetes secondary prevention strategy aimed at early identification, As a result of this initiative, there will be a reduction diagnosis and treatment, 5) developing a partnership in the incidence of teen pregnancies and STDs in the with primary care physicians in North Central Regina Aboriginal population. to improve access to primary care services that would lead to early identification, diagnosis and treatment of Type II diabetes, 6) having the Four Directions Community Health Centre increase screening, Diabetes diagnosis and support for residents suffering from Type II Diabetes, and 7) based on the continuing work Background of the Tri-District Diabetes Management Program Committee, developing a team-based service plan to First Nations and Métis people and service providers coordinate, multi-disciplinary, region-wide approaches who were interviewed during the Aboriginal Health for the treatment of diabetes. Once developed, the Initiative expressed alarm at the prevalence of diabetes plan will be submitted to Saskatchewan Health for among Aboriginal people. The 1991 Aboriginal funding. People’s Survey found that 7% of Aboriginal adults in Regina reported having diabetes, double the 3.4% Resource Requirements rate reported in the province. The Interim Report of the Saskatchewan Advisory Committee on Diabetes The diabetes initiative would require funding of found that 4.5% of the registered Indian population $50,000 annually (50% in the first year) to establish have diabetes compared with 3.6% of the general “Linking Community Voices” as a permanent RQHR population. However, the age and sex adjusted program. prevalence for registered Indians was 11.1%, approximately three times higher than for the rest of the population. Diabetes Prevention efforts are urgently needed to Budget RQHR Share Other Partners Total stop the increasing incidence of this 2003-2004 $25,000 $ - $25,000 serious disease. 2004-2005 $50,000 $ - $50,000 2005-2006 $50,000 $ - $50,000 Proposed Plan of Action
With respect to diabetes, a primary prevention strategy Expected Outcomes aimed at preventing Type II diabetes is proposed. This would involve: 1) working with the Collaboration A number of outcomes are expected from this Framework partners to establish an intersectoral group initiative: 1) the development and implementation of to take leadership for strategy development based on a comprehensive strategy to address Type II diabetes, the successful “Linking Community Voices” program, 2) the development of partnerships to improve 2) establishing baseline data respecting the incidence services for those with Type II diabetes with primary of Type II diabetes in the Aboriginal population within care physicians in North Central Regina, 3) an increase RQHR, 3) establishing the “Linking Community in screening, diagnosis and support programs offered Voices” pilot project as a permanent RQHR program, by Four Directions for residents suffering from Type
76 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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II diabetes, and 4) the development and submission population, and 2) expanding the use of Dental Health of a funding proposal to Saskatchewan Health to Educators so that they can work with Public Health establish a comprehensive, multi-disciplinary, team- Nutritionists, Public Health Nurses, and the schools based diabetes program within the region. to develop and deliver effective dental health promotion strategies. These efforts would focus on parent education about the impact of oral health on the overall health and well-being of children, and the importance of proper feeding and mouth care Dental Health practices.
Background Resource Requirements Rates of decayed, extracted or filled teeth among The dental health initiative involves the funding of an children in the Aboriginal population are known to be additional Dental Health Therapist, as well as high. In twenty seven inner-city elementary schools in additional supplies, to expand community dental health Regina, the student population has a 20% or greater programming in the Region. This would entail annual rate of untreated tooth decay. A large number of these costs of $70,000 (50% in the first year). students are Aboriginal preschool and school age children. In 1999, 40% of kindergarten children in the former Dental Health Touchwood Qu’Appelle Health District Budget RQHR Share Other Partners Total were found to have untreated tooth 2003-2004 $35,000 $ - $35,000 decay. Many of these were Aboriginal 2004-2005 $70,000 $ - $70,000 children. The provincial average for 2005-2006 $70,000 $ - $70,000 untreated tooth decay in this age group is 25%. Expected Outcomes Early childhood caries can be prevented by proper mouth care and feeding practices. Dental pain or infection have negative implications for a child’s eating This initiative will result in the reduction in the number and sleeping patterns, as well as their ability to of dental surgeries performed on Aboriginal children concentrate. A community based fluoride varnish and an increase in the number of Aboriginal children program is in place in North Central Regina, however, who have access to fluoride varnish and mouth rinse due to limited staff resources, it serves a very small programs. number of children. There are a small number of programs in inner city schools, but these are also not adequate to meet current needs. Aboriginal children require improved access to programs to improve dental Home Care health. Background Proposed Plan of Action An overall need to improve cultural sensitivity within With regard to dental health, a number of strategies the current health service delivery system has been are proposed. These include: 1) expanding preschool identified as a continuing challenge for RQHR, fluoride varnish programs and school fluoride /sealant however, gaps in culturally sensitive home care services programs that have been shown to arrest or prevent for Aboriginal clients is an area that requires particular dental decay in the preschool and school-aged attention. The credibility and effectiveness of services
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and programs could be improved by changing the partnerships with Aboriginal service providers in service delivery model so it is more culturally the community; and appropriate and affirming, by employing more Aboriginal service providers, and by encouraging • Improve access and effectiveness of home cross-cultural learning and sensitivity among home care services delivered to Aboriginal clients care staff. The roles of home care service providers will be reviewed in order to identify program barriers and Proposed Plan of Action reduce duplication of services. Program development will incorporate best practices from Several priority tasks have been identified: other home care programs where culturally • Develop home care services that utilize a appropriate services have already been successfully holistic approach and acknowledge the developed. interconnection of spiritual, emotional, mental and physical health Resource Requirements This will involve: 1) conducting a needs assessment to more fully identify home care program needs Existing resources can be utilized for service delivery, of Aboriginal people, as well as the need for but the development and coordination of a new team Aboriginal service providers, 2) developing a approach, as well as the staff training component of project team, including Aboriginal leaders, elders the proposed work plan, will require incremental and consumers, to review current services and plan resources. The development of training manuals and future services, and 3) developing a training manual support for the team approach will require ongoing for staff, based on research on “holistic costs of $70,000 annually (50% in the first year). In interconnected” services; addition, in order to support all RQHR Home Care staff to access cross-cultural learning opportunities, a • Develop and support an integrated team minimum of 8 hours of paid education time will be approach to home care within targeted required for each staff member. Since there are geographic areas approximately 400 Home Care staff, this would involve This would involve recruitment of Aboriginal staff one time costs of $64,000. It is proposed that these to work in all positions, from assessment to service costs be spread over two years. Once this initial training delivery. The roles of the various service providers has been completed, on-going training costs can be should be reviewed to ensure appropriate utilization of staff, based on unique needs identified within absorbed within existing budgets. the Aboriginal population. Collaboration should occur with Gabriel Dumont Institute to facilitate employment of students completing the Home Health Aide Home Care training program. The team approach Budget RQHR Share Other Partners Total will also require infrastructure and 2003-2004 $ 67,000 $ - $ 67,000 support; 2004-2005 $102,000 $ - $102,000 • Support the education and 2005-2006 $ 70,000 $ - $ 70,000 training of all staff to foster improved cultural awareness and sensitivity Expected Outcomes New approaches should be considered for pursuing cross-cultural learning opportunities for staff. In These initiatives will result in a number of short and particular, opportunities will be pursued for staff longer term positive outcomes: 1) improved cultural to increase learning and awareness through awareness and sensitivity among staff, 2) enhanced
78 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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cultural appropriateness of home care services, and collaborative “Drug Strategy” will chart a course for 3) reduction in barriers to services, and 4) improved integrated action. Recommendations will allow for the recruitment and retention of Aboriginal Home Care development of coordinated interagency workplans staff. In addition, a planning process involving key and the improvement of high priority services. Four stakeholders to review existing services and plan future pillars of addictions programming are being addressed: services would be commenced, and new, more enforcement, prevention, treatment and harm effective models of home care service delivery, based reduction. The need to have a range of addictions on best practices, would be introduced. programs and activities which are culturally sensitive and effective for Aboriginal people has been a key theme throughout the development of the strategy, and more recently, in the consultation process. Mental Health and Addictions Services The Drug Strategy will address service requirements Background for all district residents. However, there are specific implications for First Nations and Métis residents. Aboriginal citizens have asked for increased access to Once the Drug Strategy report is completed (June holistic, culturally appropriate mental health services, 2003), other human and financial resource implications as well as more effective responses to the problems will be identified. The strategies proposed here are of substance abuse and addictions. Research indicates consistent with the input from the Drug Strategy that an increasing number of clients are poor, consultations and research to date, and the specific marginalized, and Aboriginal. Increasing the number tasks outlined below, once approved, can be readily of aboriginal health service providers is fundamental incorporated into the broader, inter-sectoral Drug to meeting these needs. The application of traditional Strategy workplans that are now being developed. and contemporary First Nations and Métis knowledge, beliefs, and healing practices is also essential. Proposed Plan of Action Moreover, Aboriginal cultural awareness and learning opportunities are required for all managers and staff A number of inter-related strategies and actions are who work with First Nations and Métis clients and proposed in two priority areas: organizations concerning mental health and addictions issues. • Increase Mental Health services for Aboriginal people and improve coordination and integration Contemporary thinking about effective program with services provided by other agencies. This will strategies calls for more emphasis to be placed on harm involve: 1) recruiting and retaining Aboriginal staff reduction and transition to healthier lifestyles. for mental health and addictions programs and, Developing an integrated, holistic approach for more immediately, completing staffing at the Aboriginal clients will be a challenging prospect for Randall Kinship Centre, 2) refining program service providers and managers, and these new components at the Randall Kinship Centre for approaches will require far-reaching and on-going cultural sensitivity, and monitoring programs to change management. The RQHR is currently insure implementation of evidence-based practice, reorganizing programs to combine mental health 3) more effectively linking adult mental health and services and addictions services to respond to the addictions programs, 4) developing more culturally changing needs of clients. sensitive treatment programs for Aboriginal people with gambling problems, 5) recruiting mental health A broad consultation and planning process involving and addictions staff allocated to support the Kids a number of agencies is now underway to develop a First Initiative, and developing their role in inner region-wide plan to address drug abuse. This city communities, 6) developing program
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components at the Mental Health and Addictions services incorporate Aboriginal traditions and clinics that incorporate Aboriginal traditions and teachings. Hiring an Aboriginal person to lead this teachings related to gambling, alternatives to work, funds for training events, and honorariums violence, and addictions programs, and 7) for Aboriginal teachers and Elders will be required. developing health promotion strategies focusing on Partial year funding of $40,000 in 2003-2004 will mental health and addictions that are appropriate be required. This requirement will increase to to Aboriginal populations; and $80,000 in 2004-05, but will decrease to $40,000 in subsequent years as approaches are consolidated; • Develop and implement strategies to address the rise in intravenous drug use and the need to address • Developing mental health and addictions health the lack of detoxification and addictions treatment promotion strategies appropriate to Aboriginal services for Aboriginal youth. This will involve: 1) populations is a priority. The region’s mental health developing training and consultation strategies promotion manager can oversee and assist with involving First Nations and Métis service providers this work. Additional funds for service contracts regarding suicide intervention and tragic events to consult with Aboriginal groups, develop response, 2) continuing to partner with the Paul materials and approaches and assess their Dojack Youth Centre staff and community effectiveness will be needed. Annual funding of partners to deliver a dual diagnosis (mental health $30,000 is required to support these efforts; and addictions) program, 3) further refining the • Developing training and consultation strategies programming, and evaluating the effectiveness of involving First Nations and Métis service providers the Harm Reduction Clinic (methadone treatment), regarding suicide intervention and tragic events and 4) developing a Drug Strategy for Regina and response can be joined with the above noted for the region that will respond to the aspirations activities. Additional contract funds of $20,000 per and needs of First Nations and Métis people. year are required; and
These two areas of development, and the various tasks • The Drug Strategy for Regina and for the region associated with their implementation, will significantly must respond to the aspirations and needs of First improve mental health and addictions services for First Nations and Métis people. Culturally appropriate Nations and Métis residents of the region. substance abuse treatment for Aboriginal youth, and the need for a range of preventive initiatives Resource Requirements specifically for Aboriginal populations have been identified in the consultation process. The region A number of the above noted initiatives can be will need some flexible funds to participate in the undertaken by realigning existing resources. These priority recommendations and actions which are include the re-organization of current programs, being developed. $40,000 has been identified for staffing of existing positions, program development 2003-04. Ongoing annual funding of $100,000 to take into account cultural sensitivity, and cultural would allow RQHR to implement the awareness initiatives. recommendations of the drug strategy that relate to Aboriginal people. Priority initiatives that require incremental resources include: Mental Health and Addictions • A training and development plan is Budget RQHR Share Other Partners Total required to ensure program 2003-2004 $130,000 $ 40,000 $170,000 components and approaches in 2004-2005 $230,000 $150,000 $380,000 Mental Health and Addictions 2005-2006 $190,000 $200,000 $390,000
80 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Expected Outcomes limited, but the exact extent of these resources within the region is not well known. The specific outcomes expected from these initiatives include the following: Many health and human service organizations are striving to involve Elder human resources in • Recruitment and retention of Aboriginal staff in meaningful ways, however, strategic action is needed mental health and addictions is increased; to firmly establish their participation. This is a common need and a common desire of the RQHR • The quality and cultural sensitivity of programs at and of all the partners who will become involved in the Randall Kinship Centre is improved; the Collaboration Framework. Therefore, collaborative action on this priority is needed. Particularly • More culturally appropriate and accessible challenging is the bridging of Traditional and Western treatment programs are available for First Nations medicine and the incorporation of traditional healing and Métis people with gambling problems; and ceremonial practices within the mainstream health • Aboriginal traditions and teachings are more delivery system. effectively integrated into the programs at the At present, First Nation Elders are utilized in the Mental Health and Addictions clinics; programming of the Four Directions Health Centre, • New and more effective mental health promotion Randall Kinship Centre, Native Health Services and strategies are developed and made available to First the Representative Workforce Program. Program Nations and Métis residents of the region; and directors and supervisors continue to work on opportunities for Elder inclusion, however, this work • A broad strategy for addressing addictions issues is occurring in the absence of region-wide policies or in Regina and area is developed with a specific focus plans. on actions which have begun to have a positive impact on Aboriginal people in RQHR Policy is needed to support the inclusion of Elders communities. and to develop the spirituality components of current programs and services. As mentioned, some Elder inclusion efforts have commenced on a less-than- formal basis, however, continuing efforts are needed to establish common understandings, protocols, First Nations and Métis Elders, Cultures approaches and practices across the region. and Spirituality Proposed Plan of Action Background Several priority objectives and activities have been Aboriginal citizens have strongly expressed the identified: importance of culture and spirituality to individual, family and community health. Elders and other • Increase opportunities for First Nations and recognized community resource people are the Métis Elders to be involved in health “keepers” of traditional and contemporary knowledge programming, especially for the benefit of youth. about culture and spirituality and, therefore, they must This will require the development of policies and be included in the development of effective and protocols that are not currently in place; efficient programs, services and supportive policies. The involvement of Elders is essential if programs • Maintain an up-to-date registry of Elders. Who are to be culturally appropriate. Elder and Traditional are the Elders? Are they accepted and recognized Healer human resources are thought to be quite by their communities? Where do they live? What
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services could they provide? How should they be • Develop policy and protocols. As already approached? The File Hills Qu’Appelle Tribal mentioned, policies and protocols are needed to Council has developed a preliminary listing of support the inclusion of First Nations and Métis elders that are available for specific services. The Elders and spirituality within RQHR services. RQHR could utilize this list and expand it to include Elders throughout the region. Policies and Resource Requirements protocols about why, how and when we might best engage Elders in a range of activities is also needed; A number of the above noted priorities can be addressed with existing resources. These include the • Develop an Oskapewis capacity within the clarification of staff responsibilities, the creation of RQHR. It has been suggested that the perspectives mentoring opportunities and the development of of Elders can and should be transmitted by their policy and protocols. However, action on other “Oskapewis” — a Cree word meaning young priorities will require new resources. person or helper. One or more such persons could work in collaboration with other partners. They Tobacco is the traditional and ceremonial offering that could be responsible for ongoing Elder relations Elders receive for their assistance. Giving monetary and for coordinating Elder participation in honoraria to Elders as recompense for their time and programs, services, ceremonies and decision- expenses is also becoming a standard practice. Budgets making processes. One suggestion is to have this should reflect these costs so that funds are readily capacity funded by RQHR, but the individuals accessible to those working with Elders and other could be hired and supervised by the Tribal cultural and spiritual resource people. It is Council. For example, an Oskapewis could work recommended that $70,000 be allocated annually for out of the RQHR’s facilities, while being under this purpose. the supervision of the traditional healers employed by the Tribal Council; Preparing and maintaining an inventory or registry of First Nations and Métis Elders would require personal • Clarify responsibilities of existing staff. contact and relationship building with Elders across Aboriginal Community Development Coordinators the region. If such a project were to be undertaken as and other First Nation and Métis staff should act a separate project, it might involve hiring staff and as a resource to the region to enhance Elder considerable travel costs. As an alternative, RQHR inclusion and the inclusion of Aboriginal spiritual could look to the strengths and capacities of the knowledge and practices in programs and services partners who will become involved in the delivered by the region. More explicit recognition Collaboration Framework. For example, a grant to the of this role is required. First Nation and Métis staff Treaty Four (say $60,000 annualized for salary, benefits collective meetings, for the purpose of fostering a and travel) might permit them to hire one or more mentoring system, is recommended; helpers who could work out of RQHR facilities. A similar arrangement could be made with the Métis • Make Elder services available to RQHR Nation. These individuals could be responsible for employees through EAP. First Nations and Métis establishing and maintaining the registry, and for staff of the district want to have access to Elders coordinating the involvement of Elders within the and traditional healing through EAP. The region. Similarly, the RQHR might consider recognition of Elder services and traditional healing contracting with the Indigenous Peoples Health through the EAP program would demonstrate the Research Centre located on the University of Regina region’s recognition of the importance of these campus, to complete a baseline study of the current services; and state of Elder resources and traditional healing within the region. RQHR’s grant (one time costs of $20,000)
82 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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could likely be matched with an equal contribution Nations and Métis peoples would be enhanced; and from university resources. • RQHR would have the opportunity to continue to The budget forecast assumes half year costs in 2003- build relationships with Treaty Four and SIFC. 2004, except for the above noted study. This would be a one time cost incurred in 2003-2004.
Elders, Cultures, Spirituality Education, Employment and Budget RQHR Share Other Partners Total Training 2003-2004 $ 85,000 $ 20,000 $105,000 2004-2005 $130,000 $ - $130,000 Background 2005-2006 $130,000 $ - $130,000 The former Regina Health District and the provincial government Expected Outcomes through the Department of Government Relations and Aboriginal Affairs, signed a Partnership The adoption of these measures would help to ensure Agreement in 1996. This agreement committed both that RQHR and its partners provide service and parties to work together to improve opportunities for develop programs that are effective and appropriate Aboriginal people in employment, education, training for First Nations and Métis peoples. Specific outcomes and economic development. At the time, RHD decided would include: to include other designated groups (e.g., persons with disabilities) within its plan, however, the initial focus • An increased body of knowledge and of attention was the Aboriginal community. understanding about Aboriginal spiritual, cultural In 1997 an Aboriginal Representative Workforce and social aspects of health and healing would be Coordinator was hired and a Partnership Steering reflected in decision-making and service delivery; Committee was formed. A five-year strategic plan was developed by the Partnership Steering Committee, • A wide network of contacts with First Nations and which includes representatives from RQHR, the Métis Elders, Helpers and resource people would RQHR’s affiliates, SAHO, the provincial government be established; and the unions.
• Policies that expressly support the inclusion of In 1999, the former RHD completed a workforce Elders and Aboriginal spirituality would be survey to get a snapshot of how the designated groups developed and adopted; were fairing in the workforce. The survey indicated the Aboriginal group had the lowest representation in • Creative approaches to draw on the strength of the workforce. This has further reinforced the need Western and Aboriginal healing traditions would to focus on strategies related to Aboriginal inclusion. be explored and adopted; Proposed Plan of Action • The RQHR would greatly enhance its capacity to facilitate and coordinate Elder participation; Six key areas for action have been identified. In each of these areas, RQHR will work with the Collaboration • The effectiveness and efficiency of various Framework partners to seek to have a broader programs and initiatives intended to benefit First influence and more positive outcomes:
Chapter 5: Enhancing RQHR’s Capacity 83
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• Building Organizational Commitment and 6) presenting information on health careers to Capacity students in the school system, as well as in training This will involve: 1) Continuing to build institutions, 7) maintaining and increasing pre- understanding of the Representative Workforce employment training programs for Aboriginal Program by promoting the program and policy with individuals, 8) continuing to offer short-term work all internal staff, 2) allocating funds to support experience opportunities and expanding those program initiatives, and 3) expanding the opportunities within the RQHR, 9) continuing to Partnership Steering Committee to reflect recent hire Aboriginal nursing students with funding district amalgamation; provided from Health Canada’s Indian and Inuit Health Careers Program, 10) working with First • Preparing the Workforce Through Education Nations and Métis communities to develop and and Training deliver new training programs that will further This will involve: 1) working with the Partnership advance the employment of Aboriginal people, 11) Steering Committee’s Preparing the Workforce sub- increasing the retention rates of Aboriginal committee, as well as RQHR’s Education Services, employees, be reviewing reasons for discharge, and to develop an education plan to deliver First 12) developing and improving the networking Nations and Métis historical, social and cultural among Aboriginal employees of RQHR. The goal awareness programs and representative workforce is not only to promote employment in entry level leadership training sessions for RQHR staff, 2) positions, but to systematically promote the working with the Saskatchewan Association of involvement of First Nations and Métis employees Health Organizations, Government Relations and throughout the organizational structure, including Aboriginal Affairs, CUPE and RQHR’s Education in positions with managerial, planning and research Services to develop and deliver Aboriginal responsibilities; Awareness Training sessions to unionized employees with regard to representative workforce • Promoting Economic Development language in CUPE collective agreements, 3) This will involve working with the Partnership developing a proposal to Government Relations Steering Committee’s Economic Development and Aboriginal Affairs to hire an Aboriginal sub-committee and RQHR’s Financial Services to Awareness Education Consultant and a part-time develop procurement policies supportive of Administrative Assistant, and 4) every month, Aboriginal organizations and enterprises; presenting education and awareness programs to all the new employees who have started with the • Building Community Relations region; This will involve: 1) continuing to foster positive relationships with all of the agencies, organizations, • Enhancing Employment Opportunities and government departments that work with This will involve: 1) working with the Partnership Aboriginal people to create an awareness and Steering Committee’s Employment Enhancement understanding of the RQHR’s commitments and sub-committee to increase the employment of expected outcomes, 2) informing the community Aboriginal applicants, 2) working with the RQHR’s of opportunities in health care, and 3) integrating Human Resource Consultants to encourage the the work of the Representative Workforce Program inclusion of Aboriginal applicants in candidate into region-wide plans related to improving First pools for external postings, 3) actively seeking Nations and Métis health outcomes; and qualified Aboriginal people for all available positions, 4) advertising/circulating external • Monitoring and Evaluating Initiatives postings through Aboriginal networks, 5) attending This will involve developing methods to evaluate career fairs geared to the Aboriginal community, the above noted initiatives on a regional basis.
84 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Together, these initiatives will significantly increase • The number of RQHR departments participating RQHR’s contribution to First Nations and Métis in representative Workforce program initiatives will employment, education and training. increase;
Resource Requirements • Procurement policies for Aboriginal businesses will be established and implemented and these will have The above noted activities can be accomplished with positive benefits for Aboriginal employment and an enhancement to the staffing of the existing economic development; Representative Workforce Program. Current program costs are $115,000 per annum. The addition of a • The number of Aboriginal organizations who wish Representative Workforce Consultant and a part-time to enter into collaborative partnerships with the Administrative Assistant (wages, benefits, travel, etc.) RQHR will increase; and would be an additional $90,000.00. For 2003-2004 and 2004-2005, these costs would be shared by the • The results of the Representative Workforce provincial government. Program will be more systematically reviewed and evaluated on an annual basis.
Education, Employment and Training Given the relatively small investment Budget RQHR Share Other Partners Total involved and the availability of cost- 2003-2004 $45,000 $45,000 $90,000 sharing with the provincial 2004-2005 $45,000 $45,000 $90,000 government, these benefits are 2005-2006 $90,000 $ - $90,000 considered to be significant.
Expected Outcomes The Need for Better Planning and A number of specific outcomes are expected to result Coordination from RQHR’s commitment to enhance education, Background training and employment opportunities. These include:
• RQHR will show commitment to the During the internal consultations conducted by the Representative Workforce Program and to the WTTE project team, RQHR staff identified many Partnership Agreement that has been signed with positive RQHR programs and activities that were the provincial government; improving health outcomes for First Nations and Métis people. Many initiatives were mentioned, • The number of training sessions provided to staff including the Randall Kinship Centre, Four Directions and the number of staff being trained will increase Community Health Centre, the Aboriginal Community substantially; Development Coordinator, the Representative Workforce Coordinator, cross-cultural awareness • The number of Aboriginal people being employed programs, the methadone program and harm will increase; reduction initiative, Elder participation, Native Health Services at the hospitals, the needle exchange program, • The retention level of Aboriginal staff will improve; and many others. At the same time, staff in a number of different groups observed that there was often little • The number of pre-employment programs offered, awareness about many of these activities (within or including the number of work placements (on the outside the RQHR), and that there were opportunities job training programs), will increase; to improve communications, coordination and
Chapter 5: Enhancing RQHR’s Capacity 85
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evaluation, as well as the overall plan and direction In addition, such an approach would not be in keeping for the development of these services. with the principle of pooling resources to address common needs and priorities. For this reason, the bulk The need to address the RQHR’s organizational of the resources for planning, coordination, capacity related to First Nations and Métis health communicating, and monitoring should be pooled and issues has taken on increased urgency in the past year. made available to all the collaborating partners. The amalgamation of districts has resulted in a Nevertheless, it must also be recognized that there significant increase in the number of Métis and First are some responsibilities that must be discharged Nations residents within the expanded boundaries of within each organization and that will not be addressed the new RQHR, including 17 First Nation reserves or by the collaboration. These functions include, for territories, and a number of Métis communities. Many example, supporting planning, decision making, First Nations and Métis government and non- monitoring and accountability within the organization, government organizations are now within the RQHR’s integrating work plans across the organization, and boundaries. As a result, there are many new and sustaining the organizations meaningful involvement complex relationships that need to be in the Collaboration Framework. To
developed and maintained, there are ○○○○○○○○○○○○○○○○○○ insure these functions are effectively additional service needs to be carried out, RQHR will have to The amalgamation of addressed, and there are significant dedicate some resources beyond opportunities to access new resources. districts has resulted in a those that are contributed to the Additionally, both the AHI and WTTE partnership. projects are leading to an increasing significant increase in the number of projects and committees Proposed Plan of Action that require direction and coordination. number of Métis and First In order to sustain the momentum These activities have raised Nations residents within expectations in the community about that has been built up by the the on-going leadership the RQHR is the expanded boundaries Aboriginal Health Initiative and the prepared to provide. Working Together Towards of the new RQHR Excellence project, as well as to allow During the course of the WTTE the RQHR to provide leadership, the project, the Project Team became establishment of a senior position increasingly convinced that a significant and long-term responsible for coordination and commitment on the part of the RQHR would be planning of First Nations and Métis health services required to achieve the RQHR’s objective of within the region is proposed. improving First Nations and Métis health outcomes. There are many stakeholders, many complex Generally, the purpose of this position would be to relationships, a jurisdictional quagmire, long-standing promote an environment within the RQHR that and serious health and social problems, and many supports innovation and excellence in improving health opportunities to obtain additional funding and improve outcomes for First Nations and Métis peoples. This service effectiveness. Confronting the challenges and office would not have any direct responsibility for the exploiting the opportunities, however, will require a delivery of health services. These services, as well as strong, on-going commitment from the RQHR. any new services that are developed in the future, would continue to be the responsibility of line At the same time, the above noted challenges are also managers throughout the organization. The purpose ones that are faced by all the partners in the of the office would not be to “ghettoize” services for Collaboration Framework. Developing a “stand alone” First Nations and Métis people, but would be to capability to address these issues within each partner provide overall planning and coordination for these organization would lead to tremendous duplication. services.
86 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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Centralizing Aboriginal health services within one providing RQHR-wide coordination, and would also department of the RQHR is not recommended. have responsibility for liaison with senior Rather, every part of the organization should continue representatives of other organizations, including First to have responsibility for the delivery of effective, Nations and Métis governments, the location of the culturally appropriate services. office within the RQHR’s organizational structure requires careful consideration. It is recommended that The proposed position would also have an important consideration be given to having this office report role with respect to research. For example, the office directly to the Senior Vice President of Health
would monitor existing Aboriginal-related research Services. Placement within and outside the RQHR, make sure research elsewhere within the ○○○○○○○○○○○○○○○○○○ results were being appropriately used, identify gaps in organization could Every part of the existing research, assist managers throughout the undermine the RQHR in the development and implementation of incumbent’s ability organization should appropriate research plans, assist in preparing grant to provide effective proposals, and initiate and maintain partnerships with coordination, and continue to have other research stakeholders, for example, universities could also create and First Nations and Métis governments. This office perception problems responsibility for the could also assist with Aboriginal research ethics, and in the community. It delivery of effective, issues related to Aboriginal intellectual property. These would be activities would be carried out in conjunction with the counterproductive to culturally appropriate Collaboration Framework. locate the office at a level within the services The incumbent would operate according to best organization where practices in Aboriginal health and healing, and would external stakeholders also promote these practices throughout the might raise questions about the RQHR’s commitment organization and with other partners. These best to the initiative. The University of Saskatchewan, for practices, which are discussed in detail in WTTE example, has recently established a Special Advisor background reports, insure that: 1) the goal of on Aboriginal issues that reports directly to the initiatives is clearly focused on achieving equity in President of the University. Aboriginal health outcomes, 2) the underlying concept of health is holistic, 3) programs are rooted in culture, The development of the proposed new position will 4) strategies are founded on a recognition of the require that decisions be made about: 1) the place of importance of cooperation and partnerships, and 5) the position within the RQHR organizational structure, the community has voice. 2) the reporting relationship, 3) the level and classification of the position, and 4) the specific duties The incumbent would: 1) have a clear focus and and job description. Once these decisions have been objectives, 2) ensure these are relevant to the local made, the positions can be advertised, and selection community, 3) focus on excellence, 4) build on decision can be made. strengths, 5) adopt an incremental approach to development, 6) address core staffing requirements, The establishment of this new position will take time. 7) achieve synergies among teaching, research and For this reason, consideration could be given to acting service delivery, 8) pursue diverse partnerships and appointment. relationships, 9) develop organizational capacity, and 10) make appropriate provisions for evaluation, While some of the needed support for the feedback and accountability. Collaboration Framework might logically be housed within this new office, provided the collaborating Since the incumbent would be responsible for
Chapter 5: Enhancing RQHR’s Capacity 87
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partners agree on this arrangement, it is important to The creation of a senior position responsible for First remember that the RQHR is responsible for Nations and Métis health planning and coordination discharging a number of planning, evaluation, liaison would clearly signal the RQHR’s significant and on- and coordination functions in relation to its own going commitment to work with partners to improve existing and developing initiatives. Thus, irrespective First Nations and Métis health outcomes. In addition, of the arrangements that are eventually decided upon the creation of such an office would lead to improved to support the Collaboration Framework, the RQHR planning, coordination, effectiveness, communication still needs to enhance its organizational capacity to and accountability. At the moment, these address ongoing RQHR responsibilities and responsibilities are dispersed throughout the opportunities. organization and inadequately resourced. However, if the proposed new office is established, these would Resource Requirements become explicit responsibilities of the new position.
One professional staff person and a support staff position should be allocated to support this initiative. Some modest provision should also be made for ancillary expenses. An annualized amount of Budget Summary and Next Steps approximately $140,000 should be anticipated, however, the initiative would be phased in during the As the budget summary below indicates, a significant first year. number of important and inter-related initiatives are being proposed. It is recommended that the budget for these initiatives be RHQR’s Organizational Capacity approved beginning in the 2003-2004 Budget RQHR Share Other Partners Total fiscal year. 2003-2004 $ 70,000 $ - $ 70,000 As with the financial support for the 2004-2005 $140,000 $ - $140,000 Collaboration Framework, resources 2005-2006 $140,000 $ - $140,000 could become available from other sources, including the Primary Health Expected Outcomes Care Transition Fund. For present purposes, however this possibility has not been taken into account. Because of the development of a number of First Nations and Métis health services within the RQHR There are also other potential sources of future over the past decade, more attention now needs to be funding. These could also reduce the RQHR’s paid to the overall coordination and effectiveness of budgetary requirements. For example: these services. In addition, the creation of the new RQHR has resulted in more complex demands and • A specific objective of the Collaboration opportunities for funding and service improvement. Framework is to re-align existing resources so that Expectations on the RQHR are also increasing, in part they are more supportive of agreed upon priorities. because of the RQHR’s own initiatives. Relationships Other organizations have access to funds, and these are multi-faceted and overall coordination is a could be used to support the priorities that have significant challenge. For all of these reasons, it would been identified; be timely for the RQHR to consider increasing its organizational capacity to deal with these issues and • A specific function of the new position responsible opportunities. for First Nations and Métis health services planning and coordination is to assist RQHR and its partners
88 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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to access additional funds from government and These opportunities hold the very real promise of other sources. The analysis conducted by the significantly increasing resources for First Nations and WTTE team indicates that there are many Métis health services in the months and years ahead. significant funding opportunities that are not However, funding for the initiatives that have been currently being pursued. There is every reason to identified is required now, both to demonstrate believe that a dedicated effort to tap into these commitment and to get the ball rolling. resources will meet with considerable success; In addition, it is not realistic to expect that incremental • RQHR continues to dialogue with the provincial resources will be available for all the important government about increased support for Aboriginal Aboriginal health initiatives that the RQHR wishes to health services, both through the Primary Health undertake. Therefore, continuing efforts will be Care Transition funding and from other sources. required to ensure that Aboriginal health issues are This is a high priority with Saskatchewan Health, recognized as a priority within existing programs and and RQHR is well positioned to work with the budgets. Ongoing efforts will be needed to create a provincial government and other partners to play culture within the organization that recognizes First a leadership role in the province; and Nations and Métis health outcomes are critical to the RQHR’s mission. Ongoing planning, decision making • If the federal and provincial governments act on and monitoring will be required to ensure an the recommendations of the Romanow appropriate allocation of financial and human Commission, additional funding will become resources is made available to support these objectives. available for services in rural and remote areas. The Commission has recommended that some of these For some of the stakeholders, a larger group format funds be specifically earmarked for improved is appropriate. However, for proposed core partners in the Collaboration Framework, a one-on-one Aboriginal health services. approach is recommended. The presentation of the findings and the eliciting of feedback from these key organizations should be seen as the next important step in RQHR Capacity Development Budget Summary continuing to build strong Initiative 2003-2004 2004-2005 2005-2006 relationships. Infant Mortality $ 128,000 $ 80,000 $ 80,000 Breast Feeding $ 38,500 $ - $ - Once these consultations Hospital Admissions $ - $ - $ - have been completed, a final Continuity of Care $ 70,000 $ 120,000 $ 120,000 report should be taken Infant/Child Development $ 35,000 $ 70,000 $ 70,000 forward to the RQHR’s Food Security $ 12,000 $ 12,000 $ 12,000 senior management and Teen Pregnancy/Sexuality $ 12,000 $ - $ - RQRHA. Their support will Diabetes $ 50,000 $ 50,000 $ 50,000 be critical to ensuring that the Dental Health $ 35,000 $ 70,000 $ 70,000 necessary budgetary and other resources are made Home Care $ 67,000 $ 102,000 $ 70,000 available to implement key Mental Health and Addictions $ 130,000 $ 230,000 $ 190,000 recommendations. While this Elders/Cultures/Spirituality $ 85,000 $ 130,000 $ 130,000 is occurring, other partners Employment/Education/Training $ 45,000 $ 45,000 $ 90,000 in the Collaboration Planning and Coordination $ 70,000 $ 140,000 $ 140,000 Framework will have an opportunity to consult within Total $ 777,500 $1,049,000 $1,022,000 their own organizations.
Chapter 5: Enhancing RQHR’s Capacity 89
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A public communications strategy should also be Conclusion developed and implemented. The completion of the The RQHR and its partners in the WTTE initiative WTTE project represents a major milestone in the believe the current Aboriginal health outcomes in the RQHR’s commitment to improving First Nations and RQHR are unacceptable. For this reason, over the last Métis health outcomes. This accomplishment should decade, a number of prevention, community be celebrated and the results should be communicated development and direct service programs to address to interested stakeholders, as well as to the public. Aboriginal health needs have been developed. At the same time, Aboriginal governments and organizations Current planning processes within the RQHR, have been developing a broad range of community- including the work of the Aboriginal Health Initiative based, holistic health, justice, social services and child Internal Working welfare programs. As a result, there is now an
○○○○○○○○○○○○○○○○○○ Group, should unprecedented opportunity to build on considerable continue during this There is now an expertise and important working relationships to time. The develop more effective strategies for working together. unprecedented opportunity development and implementation of Despite past commitments and initiatives, significant to build on considerable various Aboriginal disparities in Aboriginal health and social outcomes primary health care expertise and important remain. The RQHR and its partners recognize that initiatives should existing services and systems do not always work well working relationships to also continue. and, sometimes, they fail Aboriginal people completely. Therefore, as important as past initiatives have been develop more effective There is also a to the health and well-being of Aboriginal residents continuing role for of the RQHR, real progress will require that many strategies for working the WTTE team. organizations increase their participation and support, Follow-up activities together and work more closely together. include disseminating the The WTTE partners have a vision of many report findings, organizations working together to address the incorporating suggested improvements, supporting the determinants of health. By working together, the RQHR in the establishment of the Collaboration, partners believe the region can play a leadership role coordinating Aboriginal primary health care initiatives by demonstrating: 1) how the health and well-being across the RQHR. of First Nations and Métis people can be restored and maintained through effective, culturally Once the position is established, the structure, appropriate primary health care services, 2) how better membership and function of these groups should be coordination involving health, justice, education and reviewed. As the new position will have responsibility social services can be achieved, 3) how services in for region-wide planning and coordination, new ideas Aboriginal communities and urban centres can be for involving and coordinating the activities of key better coordinated, and 4) how the strength and vitality stakeholders across the RQHR will undoubtedly come of Aboriginal families, communities and Nations are forward. foundations for more effective health and healing strategies.
The general approach adopted here is to: 1) identify key issues, 2) insure needed information is available for planning purposes, 3) commence action and dialogue in priority areas, and 4) prepare to bring the
90 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action
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issue forward to the Collaboration Framework for the development of joint plans and actions that will have a significant long-term impact. Thus, the immediate actions that are being proposed are intended to provide a significant but measured response to priority First Nations and Métis health issues, recognizing that other related initiatives, including the work of the Collaboration Framework, will be proceeding at the same time.
The proposed initiatives have a five-fold purpose: 1) they are intended to bring about improvements in First Nations and Métis health outcomes where these improvements can be attained quickly and with a reasonable investment of resources, 2) they are intended to increase cultural sensitivity and awareness, 3) they are intended to increase access to information that will be critical to future program planning and evaluation, 4) they are intended to improve priority services by selectively increasing staff resources, and 5) they are intended to create the opportunity for joint planning and joint action with key partners, including those who will become involved in the Collaboration Framework. Once approved, further details respecting these initiatives will be developed, actions will be coordinated across the region, and further discussions will be initiated with key partners.
It is time to implement changes to longstanding service delivery practices and models that have been far too segmented, and far too focused on illness, not health. The foundation for a new approach is the recognition that important contributions must be made by many organizations. Organizations must be brought together to develop joint plans and implement joint action. Considerable progress towards this goal has already been achieved. The region is well positioned to take advantage of current opportunities and, by doing so, will continue to build on a reputation as a leader in Aboriginal health and healing services.
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92 Improving First Nations and Métis Health Outcomes: A Call to Collaborative Action