Governed by Contracts: The Development of Indigenous Primary Health Services in Canada, Australia and New Zealand

Josée G. Lavoie, PhD Candidate London School of Hygiene and Tropical Medicine Health Policy Unit

Abstract

This paper is concerned with the emergence of Indigenous primary health care organizations in Canada, Australia and New Zealand. In Canada, the adoption of the 1989 Health Transfer Policy promoted the transfer of on-reserve health services from the federal government to First Nations. In Australia, Aboriginal Community-Controlled Health Services first appeared in the 1970s because of community mobilization. It aims to provide some access to free health care to Aboriginal People. A more recent model, the Primary Health Care Access Program, aims at guaranteeing Aboriginal access to comprehensive primary health care services under the authority of Regional Aboriginal Health Boards. In New Zealand, Maori providers emerged because of the market-like conditions implemented in the 1990s. This study compares the policy and contractual environment put in place to support Indigenous health providers in Canada, Australia and New Zealand, using a case study approach. Results show that the contractual environment does not necessarily match declared policy objectives, especially where competitive models for accessing funding have been implemented. Key Words

Primary health care, policy, self-determination, Indigenous People, health care financing, fourth sector INTRODUCTION needs of that group; and to promote their political as- This paper is concerned with the emergence of a pirations involving a renegotiation of their relation- fourth sector in Canada’s, Australia’s and New ship with the nation-state. Key features include in- Zealand’s health care systems. The health care litera- creased responsiveness to local Indigenous needs; ture generally acknowledges the government, the pri- increased opportunities for employment; and in- vate sector and non-profit, and non-government orga- creased cultural expression in health care delivery. nizations (third sector) as the three sectors involved in The sector developed over the past 30 years. It is now the delivery of health care services. A fourth sector endorsed and actively promoted by all three govern- has now emerged with distinctive features. It includes ments as a mechanism to improve Indigenous partici- Indigenous primary health care services. It is funded pation in health care, increase access and reduce in- with public dollars to provide services to an Indige- equities. nous constituency that is considered high risk because Indigenous People appear to have seized upon the opportunity to become primary health care providers. of colonial policies and socio-economic marginaliza- 1 tion. Like the third sector, Indigenous services are in- In Australia, Peter S. Hill et al. report that the num- volved in the delivery of non-commercial social ber of Aboriginal-controlled health organizations has grown to more than 120 since they first emerged in goods. In addition, Indigenous health services are of- 2 ten tied to an Indigenous governance structure; are 1971. Health Canada reports that 71 per cent of eli- primarily designed by Indigenous groups to serve the gible communities - representing nearly half of the eligible First Nation population - are now engaged in

6 Journal of Aboriginal Health • January 2004 delivering on-reserve primary health care services. Canada, Australia and New Zealand have rights that Another 13 per cent is exploring this possibility.3 In go beyond that of other minorities. This has led to the New Zealand, the Ministry of Health4 reports that the development of different concepts of citizenship, sector grew from 23 providers in 1993 to 240 in where Indigenous Peoples can secure group-specific 1998.5 rights (more evident in issues of land and resources) This paper explores the context in which Indige- that other citizens cannot.12 nous health policies emerged and the relationship be- In health care, these group-specific rights resulted tween policy and implementation in Indigenous pri- in the development of different jurisdictional respon- mary health care services in Canada, Australia and sibility and policies. For example, in Canada, First New Zealand. The paper begins by exploring key con- Nations affairs have been under federal jurisdiction ceptual issues. This is followed by a case study of since Confederation. First Nation health has been un- each Indigenous health care sector, emphasizing his- der the federal department of health (Health Canada) torical, legal and administrative factors. Each case since 1944. Health care for other Canadians is under study is based on an extensive review of literature and provincial jurisdiction. In Australia, Aboriginal affairs key documents, following the methodology described were initially under state jurisdiction along with other by Robert K. Yin6 and Barbara McPake and Anne Australians. However, the failure of the states to pro- Mills.7 The Canadian material is supplemented and vide adequate services led to the emergence of the put into context by the author’s 10 years of working Aboriginal Community-Controlled Health Services for Indigenous-controlled health services. The Aus- (ACCHS) movement. It shifted Aboriginal health tralian and New Zealand material was gathered during from states to the Commonwealth Government in the fieldwork done between June 2001 and April 2003. early 1970s and finally to the Commonwealth Depart- Each case study begins by providing some historical ment of Health in 1995. In New Zealand, Maori context, then exploring issues of jurisdiction, policy health and health care have been included under the and financing as they affect the fourth sector.8 The authority of the Ministry of Health and delegated to discussion section provides a more detailed analysis the purchasing authority of the day. The New Zealand of the relationship between health policy objectives government has continuously recognized a treaty- and the Indigenous health sector. A final conclusive based partnership relationship with Maori. This has section summarizes key findings and proposes areas been expressed in a commitment to “by Maori for for further international comparative research. Maori” health services. As shown in Table 2, the current health policies of THE NON-PPROFIT AND all three countries reflect a commitment to primary INDIGENOUS SECTORS: health services “for Indigenous People by Indigenous People.” Both Canadian and New Zealand policies Frameword for Comparison make clear reference to the legal framework explored in Table 1. In all three countries, policies also empha- Despite significant differences, Canada, Australia size the need to address the health inequalities experi- and New Zealand share a remarkable number of sim- enced by Indigenous People in comparison with their ilarities, making them amenable to comparative national counterparts (see Table 3). Indigenous People analysis. Over the past decade, numerous studies understand these inequalities as the result of historical have emerged analysing the political and legal space and present policies that limit their ability to exercise Indigenous Peoples occupy in all three countries.9 control over their own affairs.13 At a time when equity Epidemiological comparisons have also been theory dominates the health care literature, all three pursued.10 governments portray the development of Indigenous All three countries share a history of colonization by Britain, leading to the development of a compara- ble political and legal context. This legal framework EDITOR’S NOTE emerged because of historical legal documents having In New Zealand, Maori is typically spelled with a macron accent (straight horizontal line) above currency today and/or because of international pan-In- the letter a. However, most Canadian computer digenous representations that led to the ratification of keyboards and printers cannot print this international agreements ratified by all three coun- symbol. For that reason, this article spells 11 tries. This is summarized in Table 1. This frame- Maori without the accent. work establishes that the Indigenous Peoples of

Journal of Aboriginal Health • January 2004 7 Lavoie

Table 1: Foundation for Indigenous Relations in Canada, Australia and New Zealandi

Canada Australia New Zealand

International •1957 International Labour Organization Convention no. 107 and Recommendation no. 104 Covenants ratified by stipulates that indigenous peoples have rights separate from those of other minorities. all three countries •1963 United Nation Declaration and 1965 International Convention on the Elimination of all forms of Racial Discrimination (ICERD), signed in 1966 and ratified by Canada in 1970, Australia in 1975 and New Zealand in 1972. It committed each country to introduce measures of compliance. •1966 International Covenant on Civil and Political Rights (ICCPR), ratified by Canada in 1976, Australia in 1980 and New Zealand in 1978. Article 27 guarantees the right of minorities to practice their religion and speak their language.

National Legal Basis • 1763: Royal Proclamation • Legal doctrine of terra • 1840: Treaty of Waitangi • 1867: Constitutional Act nullius, literally uninhabited • 1852: Constitutional Act • 1876: Indian Act (amended land allows for Maori specific in 1985). • 1967 Constitutional provisions • 1870-1920: Treaties amendment making • 1975: The Treaty of • 1982: Constitutional Act is Aboriginal Affairs a Waitangi Act (establishing amended. Section 35 Commonwealth jurisdiction. the Waitangi Tribunal to recognizes Aboriginal • 1975 Racial Discrimination hear grievances and rule on People’s Inherent Right to Act disputes between Maori and Self-Government • 1992 Mabo case ruling the Crown) • 1982: Charter of Rights and rejects the validity of terra • 1986: All Maori references Freedoms nullius, thus confirming the disappear in the 1986 existence of Aboriginal land Constitutional Act rights that precede and • 1990: New Zealand Bill of survived colonization. Rights Act i Catherine J. Inors, Magallanes, “International human rights and their impact on domestic law on Indigenous People’s rights in Aus- tralia, Canada and New Zealand,” Indigenous Peoples’ Rights in Australia, Canada and New Zealand, (ed.) Paul Havemann, (Ox- ford: Oxford University Press, 1999). ii Based on Health Canada, Indian Health Policy 1979 (Accessed 2001), (Health Canada Medical Services Branch, 2000); and Health Canada, Transferring Control of Health Programs to First Nations and Inuit Communities, Handbook 1: An Introduction to all three approaches (Health Canada, Program Policy Transfer Secretariat and Planning Health Funding Arrangements, 1999). iii Based on: Australia Aboriginal and Torres Strait Islanders Commission, “ATSIC health policy” (ATSIC National Policy Office, 2001); and National Aboriginal and Torres Strait Islander Health Council, National Aboriginal and Torres Strait Islander Health Strategy, Consultation Draft (NATSIHC, 2001). The Aboriginal and Torres Strait Islander Commission (ATSIC), a statutory body of the Commonwealth Government has a responsibility to monitor health delivery and advise the Minister for Aboriginal and Torres Strait Islander Affairs on its effectiveness. ATSIC holds an advisory role to the federal Department of Health and Aging (DHA) who assumed the responsibility for the administration of Indigenous health in 1995. DHA and ATSIC relationship is defined in a memo- randum of understanding. iv Based on: Annette King, The New Zealand Health Strategy, Ministry of Health, (2000); New Zealand Ministry of Health, The Pri- mary Health Care Strategy, New Zealand Ministry of Health, (2001); and New Zealand Ministry of Health, He Korowai Oranga, Maori Health Strategy: Discussion Document, New Zealand Ministry of Health Discussion paper, (2001). Tino rangatiratanga is the term used most often as the expression of Maori self-determination. Tino roughly translates as self. Rangatiratanga roughly translates as “evidence of breeding and greatness.” H.W. Williams, Dictionary of the Maori Language, (Wellington: Legislation Direct, 2002). Maori traditional governance structures were based on whanau, the extended family, and hapu, the sub-tribe, as the key units of gov- ernance. The iwi, or whole tribe, generally came together in times of conflicts.

8 Journal of Aboriginal Health • January 2004 Governed by Contracts

Table 2: Health Policy Frameworks in Canada, Australia and New Zealand

Canadaii Australiaiii New Zealandiv

The Indian Health Policy The Aboriginal Health Policy The 2000 New Zealand Health Policy/Strategy recognizes three pillars: hinges on nine principles. Of Strategy acknowledges that the Foundation •Community development in particular relevance to this Crown is a Treaty partner with First Nation communities; analysis include a commitment Maori. This stems from •The traditional relationship to: decisions of the Waitangi of the Indian people to the •Address health inequalities; Tribunal, the Court of Appeal federal government •Community control of and the Privy Council. It communities to achieve their primary health care services acknowledges that the Treaty aspirations; and as a preferred method of guarantees cultural protection •The Canadian health system. service delivery; and for Maori, meaning Maori will •Localized decision-making. have an important role in implementing health strategies for Maori.

Policy Objectives To achieve an increasing level To ensure Aboriginal and People will be part of local of health in Indian Torres Strait Islander Peoples primary health care services communities, generated and enjoy a long and healthy life that improve their health, keep maintained by the Indian enriched by a strong living them well, are easy to get to, communities themselves. culture, dignity and justice. and co-ordinate with ongoing care. Primary health care services will focus on better health for a population and actively work to reduce health inequalities between different groups.

Implementation The 1986 Health Transfer The draft Aboriginal Health The Maori Health Strategy Mechanism(s) Policy, Strategy recommendation on details the direction for Maori •Promoting the transfer of nine key areas. Two notable primary health care on-reserve primary health key areas include: development, highlighting three services to First Nation •A commitment to support threads: control; and the delivery of •Rangatiratanga, meaning •Ensuring appropriate comprehensive primary whanau, hapu, iwi and Maori funding be in place, health care to Aboriginal aspirations to have control allowing community-based and Torres Strait Islander over the direction and shape assessment, hiring capacity communities, particularly of their own institutions, to draft operational plans through support for communities and and negotiating. Aboriginal community- development as a People. The Health Transfer Policy controlled services; and •Building on the gains, makes no provision to promote •Supporting Aboriginal and highlighting improvements increased First Nation Torres Strait Islander in Maori and whanau ora participation in all levels of the participation on outcomes, service uptake and Canadian health care system. management of all health Maori participation services. throughout the health and disability sector. •Reducing inequalities in health care.

Journal of Aboriginal Health • January 2004 9 Lavoie health providers as the preferred mechanism to ad- over the firm are unacceptably large… the solution is dress health inequalities. The Alma-Ata declaration to create a firm without owners - or, more accurately, and the Ottawa Charter are often cited.14 to create a firm whose managers hold it in trust for Little attention has been paid to the Indigenous pri- customers.”16 mary health sector. An appropriate analytical frame- The relationship between the government health work has been lacking. This paper builds on the as- authority (Ministry of Health, its delegate or “the sumption that the literature on the third sector can purchaser”) and the third sector (“the provider”) inform an analysis of the Indigenous health sector, to hinges on two key elements: the conduct of the rela- some extent. The third sector is defined as “a body of tionship through contract and the separation of ser- individuals who associate for any of three purposes: vice recipient and the provider.17 These two elements (1) to perform public tasks that have been delegated to constitute what John Stewart18 calls “governing by them by the state; (2) to perform public tasks for contract.” The strength of this approach lies in the which there is a demand that neither the state nor for- tendency for the provider to associate more closely profit organizations are willing to fulfill; or (3) to in- with those to whom the services are provided. This fluence the direction of policy in the state, the for- potentially leads to significant learning in how to best profit sector, or other non-profit organizations.”15 A provide services. Considerable attention has been board of directors made up of elected community paid to the role the non-profit sector can play in members generally manages these organizations. H.B. meeting the needs of vulnerable populations.19 How- Hansmann writes, when “customers are so situated ever, the closer relationship between provider and that the costs to them of exercising effective control client is only useful if the learning that occurs

Table 3: Health Inequalities in Canada, Australia and New Zealand

Per cent of Age Infant Population Life Standardized Mortality Under 15 Expectancy Death Rate Rate Years Old Canadav First Nations Male 66.9 12.71 12.3 34.4 Non-First Nations Male 74.6 8.49 6.4 20.6 First Nations Female 74 7.95 Non-First Nations Female 80.9 5.28

Australiavi Aboriginal Male 56.9 20.87 18.7 39 Non-Aboriginal Male 75.6 8.39 6.05 21 Aboriginal Female 61.7 16.86 17.3 Non-Aboriginal Female 81.3 5.42 4.95

New Zealandvii Maori Male 67.2 11.89 14.1 33.1 Non-Maori Male 71.6 9.33 7.1 22.2 Maori Female 72.3 8.4 Non-Maori Female 77.6 6.05

Where no numbers exist for Female, the number for Male covers both genders. v For 1991: Frank Trovato, “Aboriginal mortality in Canada, the United States and New Zealand,” Journal of Biosocial Sciences, Vol. 33, (2001), p. 67-86. vi For 1991-96: Australian Institute of Health and Welfare, Expenditures on Health Services for Aboriginal and Torres Strait Islander People 1998-1999. AIHW Catalogue No. IHW 7, (2001). For 1992-94: Phil Anderson, Kuldeep Bhatia and Joan Cunningham, Mor- tality of Indigenous Australians, Australian Bureau of Statistics Catalogue No. 3315.0, (Australian Bureau of Statistics, 1994). For 1995-97: Joan Cunningham and Yin Paradies, Mortality of Aboriginal and Torres Strait Islander Australians 1997, Australian Bu- reau of Statistics Occasional Paper 3315.0, (Australian Bureau of Statistics, 2000). vii. For 1991: Trovato, “Aboriginal mortality in Canada, the United States and New Zealand.”

10 Journal of Aboriginal Health • January 2004 Governed by Contracts through this relationship can be shared back with the 1867. There was considerable colonial activity in purchaser and incorporated in the contractual rela- North America in the 18th century by Britain, France tionship. This is an important qualification. Richard and Spain. The Royal Proclamation, which marked G. Frank and David S. Salkever write, “Government the end of the Seven Years War, was an attempt to cre- appears to both promote and mistrust non-profit orga- ate an alliance with the Indigenous population to en- nizations in the health sector.”20 From the govern- sure the sovereignty of the British Crown. But it also ment perspective, the mistrust is based on having aimed to contain a westward expansion from the limited control over the provider while remaining ac- American colonies. It essentially stated that the In- countable for the appropriate expenditure of public digenous Peoples of Canada were not conquered and funding and the overall quality and effectiveness of retained title to their ancestral territory. Any encroach- the services delivered. From the provider’s perspec- ment on the part of settlers was to be approved by the tive, the mistrust comes from a limited ability to in- Crown, negotiated through the treaty process and duly fluence or structure the contractual environment to compensated.24 This document constitutes the ratio- access resources in a way that better fits the popula- nale for the treaty process that was to ensue. Follow- tion served and service delivered. ing Confederation in 1867 and the push to create a The Indigenous sector shares many of the above sustainable agrarian economy, the Crown engaged in characteristics with the non-profit sector. However, treaty negotiations with First Nations throughout the there are important differences. The definition pro- Prairie Provinces. The 11 numbered Treaties are land vided above must be extended to reflect the fact that surrenders agreed to in exchange for reserve land. Indigenous organizations are extensions of the They were calculated at 128 acres per family of four tribe/band/community governance structure,21 en- at the time of signature, as well as other provisions gaged in the exercise of self-administration.22 In gen- such as rations in time of famine, medicines and agri- eral, these organizations clearly express Indigenous cultural implements. For First Nations, signing the aspirations for self-determination, building on interna- treaties was an exercise in self-preservation in light of tional and national legal documents explored in Table the American Indian Wars, the demise of the buffalo 1. They are invariably engaged in the process of cul- and the devastating impact of epidemics.25 Since that tural translation; of western medical ideology, sys- time, the federal government has actively worked on tems, procedures and information to their member- limiting the sphere of influence of the Royal Procla- ship; and of member’s behaviours, beliefs, values, and mation and the treaties. The Indian Act defines in needs to the health care system. rather limiting ways the legal category of Indian, Interestingly, Canada, Australia and New Zealand which determines the right to live on-reserve and to have legitimized the fourth sector’s aspirations and qualify for certain individual-based benefits.26 role in their respective health policy.23 The implemen- The settlers who arrived at the turn of the last cen- tation of these policies has at times erred away from tury were concerned the appalling health conditions their stated goals through barriers embedded in the that prevailed on reserves would lead to the spread of contractual environment or limitations of the scope of epidemics. The federal government’s answer was to services transferred to the fourth sector. The following hire a General Medical Superintendent in 1904 and case studies explore in more detail the complex envi- set up a mobile nurse visitor program in 1922. The ronment from which the Indigenous health sector first on-reserve nursing station (now called health emerged and now operates. centres) was set up at Fisher River in Manitoba in 1930.27 Indian Health was incorporated into the Na- CANADA: tional Department of Health and Welfare when formed in 1944. Nursing stations were built on most The Challenge of Fragmented Jurisdictions reserves to provide primary health care delivered by nurses. Until the establishment of the national health In the Canadian context, primary health care ser- care system, nursing stations provided free care to In- vices for on-reserve First Nations are under federal ju- dians, on humanitarian grounds.28 The current na- risdiction. Primary health care for other Canadians, as tional health care system was established in 1970. It is well as secondary and tertiary health services, are un- a publicly-financed, publicly-administered and at least der provincial jurisdiction. This historical separation partially privately-delivered system, managed by the of jurisdiction is based on two documents - the Royal provinces under the umbrella of the Canada Health Proclamation of 1763 and the Constitutional Act of Act. Within this system, public health and primary,

Journal of Aboriginal Health • January 2004 11 Lavoie secondary and tertiary health care services can be ac- opment, the traditional relationship of the Indian Peo- cessed at no cost to the individual. On-reserve ser- ple to the federal government, and the Canadian vices in the form of health centres now complement health system.34 The first transfer was completed in this system, but remain separately funded by the fed- 1988,35 apparently in anticipation of the release of the eral government. Physicians paid by the provinces policy. Services targeted for transfer are defined by visit the health centres on a regular basis. Patients re- the federal government. They include mandatory ser- quiring secondary or tertiary care in between visits or vices such as communicable disease control, environ- in an emergency are transported to the nearest provin- mental health and treatment services (in health centres cial referral centre. The development of a national located either off the road system and/or at least 60 health care system did not end the historical separa- km from the nearest referral centre).36 Medical and tion of jurisdiction in health care. Hospital Insurance Services are excluded, as well as In 1969, the liberal government of Prime Minister Non-Insured Health Benefits that includes medica- Pierre Elliot Trudeau attempted to abolish this histori- tion, medical transportation, eye care, and dental cal separation. This was in part a response to the care.37 More recently, the federal government intro- Hawthorn Report,29 the first comprehensive survey of duced two alternatives to accommodate different aspi- on-reserve social and economic conditions. It reported rations and levels of development.38 dismal conditions and recommended an end to care Various concerns have been raised over the years. taking policies in favour of economic development. It appears First Nation services are not funded on an The government’s answer was outlined in the 1969 equitable basis compared to provincial services when White Paper calling for repealing the Indian Act, existing health inequities and cost of delivery are eliminating the reserve system and transferring the taken into account. For example, Pran Manga and land to First Nations subject to provincial legislation. Laurel Lemchuk-Favel39 documented that the com- This plan was rejected by First Nations and eventually bined 1991/92 federal and provincial expenditures for withdrawn on the strength of the Royal a comparable set of services (excluding transportation Proclamation.30 These events entrenched the histori- costs) for Ontario First Nations was only 8.6 per cent cal separation, but also gave momentum to discus- higher than that of other Ontarians. In Manitoba, the sions of self-government. The 1982 Constitutional combined expenditure for First Nations was only 0.8 amendment saw the inclusion of Section 35. It affirms per cent higher. These analyses considered actual ex- Aboriginal and treaty rights flowing from the 1763 penditures, not needs. When need is considered, they Royal Proclamation and the right of Aboriginal Peo- suggest the optimal level of per capita expenditure on ples to participate in Constitutional and other debates health services is actually 6.8 per cent lower for On- affecting them. This has become interpreted as an tario First Nations than for other Ontarians. Another open door for Aboriginal self-government. However, study, by John Eyles, Stephen Birch and Shelley what self-government actually means remains a mat- Chambers,40 show an actual shortfall of more than ter of debate. The 1993 Aboriginal self-government $700 per capita for First Nations living in the remote policy limits the powers of First Nations wanting to Sioux Lookout area of Ontario, equal to an under engage in this process to semi-municipal powers. funding of 45 per cent compared to provincial ser- Also, it appears to be more readily associated with an vices. These analyses contrast sharply with the official attempt at cutting administrative costs than meeting wisdom on the subject. The 1993 Royal Commission First Nations political aspirations.31 The federal gov- on Aboriginal Peoples41 shows the 1992/93 combined ernment further claims that self-government will re- per capita expenditures from federal and provincial duce the government’s fiduciary (trustee-like) obliga- governments for Aboriginal health is $2,282 com- tions in areas First Nations have assumed pared to $1,652 for Canadians - a 38 per cent differ- responsibility.32 First Nations have not embraced this ence.42 policy.33 Another concern is part of the funding is calculated The Health Transfer Policy was announced in based on First Nations living on-reserve at the time of 1989. It was touted as an answer to 20 years of con- the signature of the transfer agreement. There is no sultation and discussion between Aboriginal Peoples provision for population increase or for funding non- and government on the best way to deal with the in- First Nations people who may use these services. equalities existing between Aboriginal Peoples and Other transferred funding is based on historical ex- the rest of Canada. It builds on the 1979 Indian Health penditures and varies from one Health Canada region Policy that recognized three pillars: community devel- to the next.43 New initiatives, such as Aboriginal

12 Journal of Aboriginal Health • January 2004 Governed by Contracts

Headstart, are introduced on a competitive basis By the 1960s however, attitudes were shifting at all rather than needs, disadvantaging small First Nations levels of the Australian society, leading to legislative with limited access to technical expertise in grant ap- changes to end discriminatory practices. Voting was plication. extended to Aborigines in 1962. Constitutional The provincial health systems are planned and re- changes in 1967 gave the Commonwealth government formed independently from the federal-First Nation the authority to make laws in relation to all Aboriginal systems. This creates opportunities for cost shifting People, including the right to enumerate them in the between both governments or for gaps in service to annual census. Aborigines were now visible citizens emerge, leaving First Nations in a substandard or no of their own country. Since then, the government care situation.44 By virtue of being a federal jurisdic- worked towards consolidating its responsibility for tion, First Nations have only a marginal, if any, role in Aboriginal affairs. The Commonwealth Office of provincial health care reforms. Aboriginal Affairs was established in 1968. By 1972, In summary, the Canadian fourth sector has the Labour Party was elected to office and self-deter- emerged because of First Nation demands to have mination became the official policy. Commonwealth more control over their own affairs. Although the expenditures on Aboriginal Affairs doubled. By 1973, Health Transfer Policy has created opportunities for the Commonwealth government offered that state self-administration, these opportunities have been ministers assume full responsibility over Indigenous limited to the administration and delivery of pre-exist- affairs, including policy and planning. The Depart- ing services as determined by Health Canada. ment of Aboriginal Affairs (DAA) was finally given the central authority over Aboriginal policy. AUSTRALIA: In the early 1970s, the government’s version of self-determination was described as creating opportu- From Integrated to Separated Services nities for Aboriginal communities to decide the pace and direction of their future development. Eventually, Until the 1992 Mabo decision, the history of Aus- self-determination crystallized as self-management of tralia’s settlement hinged on the obscure legal concept governmental plans and projects for Aborigines in- 45 of terra nullius, literally uninhabited land. Sir cluding input in planning, development and imple- Joseph Banks, who had been on the Endeavour with mentation. From 1972, the DAA initiated direct grants Captain Cook in 1788, reported to the Crown that the to Aboriginal organizations, giving life to what Tim continent was uninhabited, except for a small popula- Rowse calls “the Indigenous sector.”50 Self-determi- tion of Indigenous People along the coast. Banks be- nation in matters of health care came to mean the lieved they were unable to negotiate the purchase of transfer of funds from the government to the burgeon- land with the Crown. In contrast with the Canadian ing Aboriginal Community Controlled Health Ser- treaty process, it was this belief in terra nullius that vices (ACCHS) movement.51 Their emergence in the justified Australian settlers in taking land without ne- early 1970s captured the imagination of many acade- gotiation or compensation. This invariably led to the mics, professionals and community activists, Aborigi- displacement of Aboriginal People - first on the nals and non-Aboriginals alike. It created much hope coasts, then progressively in the interior. By the 19th that community-based decision-making was the solu- century, depopulation from diseases and frontier vio- tion to improving Aboriginal health. 46 lence associated with land grabs had taken their tolls At that time, Aboriginal access to health care ser- and small Aboriginal groups were left to camp on the vices was limited by a number of factors. Services edge of European settlements, increasingly depending were available in some mission settlements, but for a on them for survival. As a result, comparable policies majority of Aborigines living in remote environments, of segregation and containment to protect Aborigines access to treatment was sporadic and linked to the from European excesses were being designed in all Royal Flying Doctor Service. Elsewhere, economic 47 states and territories. Areserve system was imple- limitations made access impossible because of a lack mented “as places of refuge where the dying remnants of transportation.52 When transportation was avail- 48 of the Aboriginal population could live their lives.” able, direct charges for hospital and physician care Since the creation of Australia in 1901 was a coming added difficulties. The situation was not resolved by together of separate colonies wanting to retain consid- the creation of the national health care system in erable autonomy, Aboriginal affairs remained the 1984. It can still be problematic. The government 49 realm of the states. funds and administers Medicare (the national health

Journal of Aboriginal Health • January 2004 13 Lavoie insurance system), administers the Pharmaceutical early 1990s. Despite the establishment of a national Benefits Scheme and provides grants to non-govern- health care system financed largely through taxes, ment organizations for health-related projects. It also funding for ACCHS was limited. It remained discon- finances health services provided by the states/territo- nected from mainstream funding for health services ries through the Medicare Agreements. The system is allocated to the Commonwealth Department of Com- funded through general federal taxes to the Common- munity Services and Health and by extension, to wealth and provides access to primary, secondary and state governments. This issue led the ACCHS sector tertiary care.53 Access fees are waived for low income to lobby for Aboriginal health funding to be moved Australians, but this is linked to a registration process to the Commonwealth Department of Health. This that acts as a barrier to access for some Aborigines.54 was completed in 1995 under the Office for Aborigi- In areas where there is no general practitioner, state nal and Torres Strait Islander Health (OATSIH). and territorial governments may have opted to set up ACCHS can now access limited core funding, sup- clinics staffed by nurses, thus financing activities that plemented by Medicare, if they can recruit a general are generally paid for by the government for the gen- practitioner and project funding is secured on a com- eral population. Gross inequities in access to primary petitive basis. health care remain.55 The Primary Health Care Access Program (PH- The first ACCHS was set up in the urban centre of CAP) was announced in the 1999/2000 Common- Redfern (a suburb of Sydney), New South Wales, in wealth budget. It builds on the experience of the Abo- 1971. Fitzroy (near Melbourne), Victoria, followed in riginal Co-ordinated Care Trials. These were 1973, and Perth, Western Australia, in 1974. These implemented in the mid 1990s in four Aboriginal sites services operated under the direction of an Aboriginal to test the impact of pooling state/territorial and Com- Board of Directors, offered primary health care and monwealth health funding on the development of functioned with volunteer staff (including physicians, comprehensive Aboriginal-controlled primary health nurses and community staff). It initially secured rent care services.62 PHCAP has three objectives: to in- and other necessities with in-kind donations. The goal crease the availability of appropriate primary health was to provide accessible and appropriate health ser- care services where they are currently inadequate; to vices. Some have expanded over the years, while oth- reform the local health care system to better meet the ers have retained their original clinical care focus.56 needs of Indigenous people; and to empower individ- While born as a community initiative, the movement uals and communities to take greater responsibility for has been continuously mentioned in government their own health. The plan is to carve out Australia strategies,57 a Royal Commission58 and a national in- into regions and to set up regional Aboriginal health quiry59 as the most effective way to deal with the boards to act as fund holders. The funding will pool health inequalities existing between Aborigines and money previously spent by the territory or state on other Australians.60 Recognizing the need for a com- primary health care of Aboriginal People in the region mon voice, ACCHS supported the creation of the Na- and Medicare funding calculated on a per capita basis, tional Aboriginal and Islander Health Organisation in adapted for needs and remoteness.63 Although imple- the mid 1970s,61 which became the National Aborigi- mentation is just beginning, there is high hope that nal Community Controlled Health Organisation PHCAP will significantly improve Aboriginal access (NACCHO) in 1992. State and territorial bodies to appropriate primary health care. But there are con- emerged after that. The movement has grown remark- cerns that the historical lack of investment in Aborigi- ably since it first emerged with ACCHS in each state nal education and community infrastructure develop- and the territory, operating in both urban and remote ment may create considerable obstacles. environments. New member organizations are added In summary, Aboriginal community-controlled every year. health services emerged in Australia because of the Funding for the ACCHS remains problematic. Aboriginal community organizing against the lack of Since 1968, the responsibility for Aboriginal health access to acceptable and affordable primary health shifted six times between departments. The DAA ex- care services. After years of lobbying, Australia has tended its grants program to ACCHS in 1972. But finally generated a plan to address the still-dismal ac- the funding was proposal driven and allocated annu- cess to primary health services. The plan deploys an ally. This was still the case when DAA’s successor, ambitious and appropriately-funded program that the Aboriginal and Torres Strait Islander Commis- places Aboriginal Peoples in control of Aboriginal pri- sion (ATSIC) was given this responsibility in the mary health care resources, recognizing existing in-

14 Journal of Aboriginal Health • January 2004 Governed by Contracts equities, needs and costs associated with remoteness cluded from the general roll, thereby turning the four in different regions. The PHCAP is now the most- seats into a token representation. Although the Maori comprehensive, innovative and exciting model set in preferred the establishment of a separate Maori par- place in all three countries. liament, they were ignored. The overall goal of the policy of racial amalgamation was to integrate Maori NEW ZEALAND: while buying up land and ensuring the peaceful set- tlement of New Zealand. By the 1850s and ‘60s, rela- Interpreting Treaty Obligations tions between settlers and Maori were deteriorating. Settlers saw the progressive policy of amalgamation 64 Although Maori experienced the sustained pres- as unduly sympathetic. The colonial authorities and ence of missionaries since 1815, New Zealand was missionaries’ efforts to educate Maori were perceived the last of the dominions to be annexed and settled. as wasted on a dying race. But the main source of However, there were less than 2,000 Europeans in tension was land, title to which was protected under New Zealand when Britain officially claimed sover- the Treaty of Waitangi. From 1860 to 1868, this led 65 eignty in 1840. According to Malcolm Nicolson, by to large-scale land wars and Maori land the 1830s and 1840s, it was widely acknowledged in confiscation.71 Europe that contact with Indigenous cultures had The New Zealand Department of Public Health detrimental effects on their health. While the reasons was set up in 1900. Maui Pomare, the first Maori doc- for such effects were debated, the experience of fron- tor, was appointed as the Maori Health Officer. Maori tier violence by settlers in Australia left little doubt as Councils (runanga) took on the role of assisting the to some sources. It appears that it was the British gov- department in health and sanitation initiatives.72 Hos- ernment’s intention to minimize the horrors experi- pitals were set up using colonial funds in Auckland, enced in its other colonies. The Crown’s answer was Wellington, Wanganui, and New Plymouth. These to adopt a policy of amalgamation of Maori into the were non-segregated and fully accessible to both 66 colonial legislative and governmental framework. Maori and Europeans, a phenomenon that Nicolson This approach is embodied in the Treaty of Waitangi, believes was unique in the history of British colonial which was signed in 1840 between the Crown, the administration.73 governor and about 500 Maori chiefs. The treaty in- The 1970s proved a time of rapid change. In 1975, cludes only three articles, written in broad terms and the Treaty of Waitangi Act was passed by parliament. 67 in English and Maori. Partly because of differences It removed the implementation of the treaty from the in translation, Maori understood the treaty as an in- realm of policy while providing an advisory mecha- strument of protection that would not affect their sov- nism, the Waitangi Tribunal, to assist in resolving dis- ereignty. Maori chiefs had no legal authority or man- putes. Later, the Tribunal ruled that the Treaty of Wai- date to surrender the sovereignty of the iwi (tribe) or tangi apply to both iwi and other Maori (urban, hapu (sub-tribe). Yet, this is how the Crown inter- pan-iwi) communities as long as they could demon- preted the Treaty of Waitangi. strate their exercise of tino rangatiratanga (self gov- The Constitutional Act of 1852 established a repre- ernment).74 sentative parliament and tied the right to vote to land During the 1970s and early ‘80s, Maori became in- ownership. Maori owning property could vote in ac- creasingly vocal about the need to link culture and cordance with Treaty rights and the policy of amalga- health.75 This led to a number of Maori initiatives in- 68 mation. The Native Department (later to become cluding conferences, health promotion campaigns, the Department of Maori Affairs) was set up in 1861. and community health initiatives. This included the Under the authority of the Governor and the Imperial 1984 Hui Whakaoranga, the first national Maori government, it was to establish an effective govern- health planning workshop, that recommended in- ment presence in Maori areas and undermine the ap- creased Maori participation.76 Maori argued that peal of Maori chiefs. The Maori Representation Act health could be described as taonga,77 and therefore is 69 of 1867 reserved four Maori seats in the legislature protected under Article 2 of the treaty. The New 70 to ensure some representation. That was the result Zealand government rejected this interpretation. The of pressures from the Otaki chiefs. This was meant to government argued that its responsibility in health complement the representation Maori could secure care was the same for all citizens. through general voting. However, after 1893, people Article 3 of the treaty guarantees the same rights of more than 50 per cent Maori descent were ex- for all citizens, including health. This has provided a

Journal of Aboriginal Health • January 2004 15 Lavoie solid base for Maori to argue for “a fair share of soci- Funding Authority (HFA) was created to continue the ety’s benefits,”78 including health. The 1988 policy purchasing process with national standards. Maori statement Te Urupare Rangapu79 made an unprece- providers emerged and flourished under the HFA. dented and never-repeated commitment for the Crown However, the rapid growth of the Maori health sec- to enter into partnerships with iwi. It was mandated tor has had its problems. Policies for contracting were and funded to deliver services on the Crown’s behalf. inspired by a competitive model that required the Iwi were to be formalized as legal corporations under fragmentation of public health activities into sub-con- the short-lived Runanga Iwi Act of 1990. However, tractual units.84 The result has been the growth of the Act was repealed the same year it was passed. The Maori providers funded through a multitude of Ministry of Maori Development, more commonly smaller contracts, each with its own specification, de- known as Te Puni Kokiri, replaced the Department of liverable target and reporting requirement. Many con- Maori Affairs in 1992. Maori staff began working in tracts are volume-based (with payment based on a specialist divisions in the areas of health, education, maximum number of intervention and funding capped training, and economic resource development. A at that level) or paid on a fee-for-service basis.85 The Board of Health Standing Committee on Maori Health administrative cost is considerable.86 Acursory re- was set up in 1984 to provide advice on policy. A view of the Maori Health Directorate funding 2000/01 Ministerial Advisory Committee on Maori Health re- database conducted October 2001 showed that 40 placed it in 1989. Both initiatives were short lived and Maori providers received direct funding from the Di- had limited success. However, they eventually led to rectorate.87 The number of contracts per provider the current structure of the Maori Health Directorate. ranged from one to 35 and averaged $110,000 Cdn It was put in place in 1993.80 The commitment to a per year. This seems remarkably small considering the partnership between the Crown and iwi, which im- administrative work each contract carries, both for the plies the collaboration of representative bodies of Maori Health Directorate and the Maori provider. comparable status and relevance, had been diluted The HFA was short-lived (1998-2000). It was re- considerably. placed by 21 District Health Boards (DHBs). The New Zealand’s national health care system was competitive ideology has been displaced in favour of first set up in 1938 through the Social Security Act. It co-operation. One main objective of the current re- provided universal access to general practitioners, form is to rationalize the primary health care delivery hospitals, pharmaceutical, and maternity services. It sector, where providers proliferated. This created a remained unchanged until 1980 when an economic high level of fragmentation in service delivery. The downturn and rising cost led to the introduction of implementation of the Primary Health Care Strategy88 cost-cutting measures. Major reforms were again in- requires the DHBs to promote the development of Pri- troduced in 1991. This led to the “big bang” approach mary Health Organisations (PHO). These organiza- to health care reform, the introduction of the pur- tions are funded on a per capita basis to purchase chaser-provider split and the expedient privatization and/or provide primary health care services to an en- of the delivery of health services at all levels.81 Imple- rolled population. The goal is to create a mechanism menting this plan required the collapse of the 17 Area that will bring together general practice clinics and Health Boards (1983-1993) and the creation of four providers under a co-ordinating community-based au- Regional Health Authorities. The authorities were thority as well as ensure the planning and delivery of given the job of purchasing services from independent comprehensive primary health care services. providers.82 Maori received this with a mixture of ap- Depending on the direction taken in the develop- prehension and hope. Maori organizations anticipated ment of the PHO, Maori providers may see their fund- that opportunities might develop for greater involve- ing coming from yet another authority, this time a ment in service delivery. However, at the same time, PHO of which they may be a stakeholder. It is yet un- such participation would imply a support of the com- clear whether Maori providers will continue to exist mercial overtone of the reform: “Tino rangatiratanga as an independent provider. Regional differences are and its promise of greater Maori autonomy could be anticipated, reflecting differences in policy interpreta- construed as offering implicit support for privatization tion by the DHBs rather than local Maori provider or at least for reduced State provision of services.”83 wishes. Opportunities materialized because of the second re- Despite acknowledging the document in its official form. This led to the collapse of the four Regional policies, the Crown has adopted a narrow view of the Health Authorities (1993-1998). The national Health Treaty of Waitangi. It could be argued that the lack of

16 Journal of Aboriginal Health • January 2004 Governed by Contracts a national Maori political organization is giving the Contractual Environment Crown more latitude in its interpretations. A treaty- Adifferent contractual environment has emerged based health policy has yet to emerge. With each re- for providers, as shown in Table 4. The Health Trans- form, the new purchasing authority(ies) received fer Policy and PHCAP both emerged from a separate guidelines89 to ensure the continued inclusion of jurisdictional model and reflect a closer relation be- Maori and Maori issues at three levels: tween the purchaser and the provider. Although both •Partnership: working together with iwi, hapu, remain a top down approach reflecting asymmetries is whanau (extended families) and Maori communi- power, the closer relationship provides an opportunity ties to develop strategies for Maori health improv- for the purchaser to learn and adapt the contractual ments and appropriate health and disability ser- environment based on the provider’s experience. In vices. the cases of the ACCHS and Maori providers, Indige- •Participation: involving Maori at all levels of the nous organizations must access funding through mul- sector in planning, development and delivery of tiple sources that are competitive and proposal-driven. health and disability services. The resulting contracts are notably short term and • Protection: ensuring Maori enjoy at least the same fragmented to a level that limits a productive pur- level of health as non-Maori and safeguarding chaser-provider relationship.92 The administrative cost Maori cultural concepts, values and practices.90 of this system, for the provider and the purchaser, is In summary, policy statements in New Zealand in- considerable. It yields few administrative benefits or variably refer to the Treaty of Waitangi. However, any substantial transfer of learning from the provider Maori providers remain vulnerable to shift in policies back to the purchaser.93 In the case of New Zealand, that delegate the implementation of a treaty partner- one also wonders how continuous fluctuations in pur- ship to local health authorities. This model echoes the chasing health authorities can possibly reflect the Australian ACCHS model, which is now being aban- partnership itemized in policy documents. doned. New developments may result in progress for Maori providers, or Maori providers becoming swal- Range of Services lowed by general practitioner-led PHOs. This last pos- sibility would reflect poorly on the fit between policy The services Indigenous organizations can offer and implementation in New Zealand. vary depending on access to funding and jurisdiction. In Canada, on-reserve services offer primary health POLICY AND IMPLEMENTATION care delivered by a team of nurses with an extended scope of practice, community health representatives Despite similarities, Canada, Australia and New and addiction workers. The scope of the work in- Zealand have developed different relationships with cludes treatment and rehabilitative care,94 public their Indigenous health sector. This reflects the differ- health and health promotion. Physicians visit the com- ences in the political space Indigenous Peoples oc- munities, but are not employees of the community and cupy in each country and ideology in health that de- remain funded provincially. Off-reserve services are fines the place of the non-government sector in health also out of bounds. As nearly 40 per cent of the First service delivery. For example, in Canada, the Health Nation population actually live in urban centres, the Transfer Policy has focused exclusively on on-reserve Canadian policy effectively limits the sphere over services and on the elimination of health inequalities. which First Nations can extend their influence and In contrast, both Australia and New Zealand have therefore their primary health care services. The fed- gone further and included a commitment to increase eral-provincial dual jurisdiction restricts First Nations Indigenous participation at all level of the health care ability to influence provincial health systems, includ- system. While broader in scope and noteworthy for ing services that are used by on-reserve First Nations 91 Canada, both Australia and New Zealand have com- such as secondary and tertiary care facilities. This mitted considerably less resources and support to model is closely related to the emerging PHCAP, with provider development. These differences have af- the exception that Aboriginal Health Boards are fected the contractual environment, the range of ser- funded to hire their own physicians. In contrast to the vices that can be offered by Indigenous providers and above, the ACCHS and Maori health providers may the Indigenous level of participation in shaping health offer any services for which they can secure funding. policy. Each of these themes will now be explored in Although this may appear to be a more flexible more detail. model, few providers can offer a comprehensive pri-

Journal of Aboriginal Health • January 2004 17 Lavoie

Table 4: Fourth Sector Jurisdiction and Financing

Inflexible costly contractual environment Relational contractual environment

Canada New Zealand Australia Health Transfer Australia Maori Providers ACCHS Policy PHCAP

Per Cent of the viii ix x xi Total Population 14.50 2.20 1.45 2.20 Jurisdiction for Indigenous Undifferentiated Undifferentiated Separate Historically Health undifferentiated, now separate

Historical Privatization of the Community 1986 Health Transfer PHCAP emerged in Dimension health care system in the mobilization and Policy emerged in 2000 following early 1990s, ideology of creation of clinics with response to First Nations pressures by Aboriginal competition, promotion volunteers and donated demands for increased Peoples and the of entry of providers facilities in the early self-governance. Northern Territory into market-like 1970s. Some core Government for more conditions. funding since 1995. equitable financing. Access to Funding Fragmented, Fragmented, Single main contract, Single main contract, administratively costly administratively costly some opportunity to some opportunity to and unresponsive and unresponsive compete for compete for complementary funding, complementary funding, continuous funder- continuous funder- provider relationship provider relationship

Contract Static contractual Static contractual Some negotiation Some negotiation Environment environment environment

Contract and Majority of funding More stable annual core Contracts signed for 3-5 Pooling of federal and Source of comes through the funding plus project years. Mainly state/territory primary Funding district health boards. funding since 1995. Aboriginal-specific health care funding Other funding comes Most funding remains funding from Health under one three-year from the Ministry of proposal driven. Canada with some contract, including pre- Health because of treaty opportunities for existing clinics, responsibilities. funding from other Medicare (capitation Providers report sources.xiii Core funding formulae adjusted for considerable differences based on per capita- needs and in process depending on historical expenditures, remoteness).xv the source of funding.xii capped from the time of Access to funding is signing. Project funding fragmented in multiple and new initiatives small contracts. generally introduced on competitive basis.xiv viii For 2000: New Zealand Statistics/Te Tari Tatau, Quick Facts - People, Accessed 2002, (New Zealand Statistics/Te Tari Tatau, 2002). ix For 1991-96: Australian Institute of Health and Welfare, Expenditures on Health Services. x For 1996: Statistics Canada, Statistics Canada’s 1996 Census - Aboriginal data on-line, (Statistics Canada, 1996). xi For 1991-96: Australian Institute of Health and Welfare, Expenditures on Health Services. xii New Zealand Te Puni Kökiri, Maori Provider Views of Government Funding, Key issues from the literature and interviews, (2000). xiii Josée Gabrielle Lavoie, “The Value and Challenges of Separate Services: First Nations in Canada,” Health Care: Responding to diversity, Judith Healy and Martin McKee, eds., (London: Oxford University Press, 2002). xiv A.H. Webster, Health Management by First Nations: Costs and issues (Vancouver: First Nations Chiefs’ Health Committee, 1999). xv Australia Commonwealth Department of Health and Aged Care Office of Aboriginal and Torres Strait Islanders Health Services, Primary Health Care Access Program (Accessed 2002), (OATSIH, 2002).

18 Journal of Aboriginal Health • January 2004 Governed by Contracts mary health care service because of their limited ac- This paradox has been recognized. Indigenous Peo- cess to funding and the many separate contracts re- ples have been concerned that all three governments quired to enable a comprehensive service.95 may be capitalizing on the discourse of self-determi- nation to off-load services onto the shoulders of Participation in Policy poorly-resourced Indigenous health services.96 The In all three countries, the government-purchaser re- Australian context has generated a considerable 97 tains a great deal of control over the policy environ- amount of literature supporting this argument. This ment and defines the level of participation Indigenous has led to debates and research on equity in Aborigi- People may have in the system. In Canada, the As- nal health financing, which has been matched only to sembly of First Nations has an established relation- a very limited extent in Canada. The proposal-driven ship with Health Canada and sits on planning meet- process of accessing funding, currently in place for ings advising on the development of initiatives. ACCHS in Australia and embedded in the competitive Regionally, First Nations have opportunities for input funding model for Maori providers in New Zealand, is through their regional political organizations. Some remarkably adept at shifting the responsibility for ac- provincial services provide translation and cultural li- cessing appropriate funding to the providers. This aison services to better serve the Indigenous popula- makes inquiries of equitable access to funding un- tion. Health boards may include First Nation repre- likely. It is impossible to gauge whether services sentation. But the level of input is quite limited and funded under a competitive model are indeed appro- not formally linked to the First Nation governance priately funded for what they are asked to provide or structure. In Australia, the National Aboriginal Com- whether the sector experiences barriers in securing munity Controlled Health Organisation (NACCHO) funding when compared to mainstream providers. had decisive influence over moving the Aboriginal It is apparent in Canada and Australia that the In- health funding from the Aboriginal and Torres Strait digenous health sector is a vehicle for the pursuit of Islander Commission (ATSIC) to the Commonwealth aspirations that transcend a biomedical concept of Department of Health. The planning of the PHCAP health. In Canada, this is expressed in First Nations has included both NACCHO and state/territorial Abo- taking the opportunity to exercise some control over 98 riginal political organizations. In New Zealand, the the use of the medical surveillance discourse and in purchasing organization(s) of the day receive clear joint Assembly of First Nations-Health Canada fo- policy guidelines to ensure Maori involvement at the rums. In Australia, NACCHO has been central in de- board level and in service delivery. The purchasing bates over Aboriginal health. By contrast, the repre- organization(s) of the day is also required to develop a sentation of Indigenous People is much stronger in treaty-based relationship with local iwi. But Maori New Zealand, where Maori participation has been en- participation at the policy level has been limited to in- couraged either as independent service providers or as dividual Maori being hired in high-level positions. individual Maori participants on public boards. At There is no recognized pan-Maori body to indepen- 14.5 per cent of the overall population, Maori can use dently advise at a government level. This situation, the democratic process, as well as their treaty relation- therefore, only weakly reflects policy statements of a ship with the Crown, to maintain their place and voice partnership between the Crown and iwi. their needs in the larger society. In contrast, Aborig- ines and First Nations, making up two and three per cent of the overall population, require other mecha- CONCLUSIONS nisms to ensure visibility. Separate jurisdiction may In Canada, Australia and New Zealand, Indigenous very well assist them in that task. primary health care services emerged at the juncture Despite these differences, Indigenous organizations between an Indigenous commitment to self-determi- in all three countries are attempting to redesign west- nation and ideological influences in national health ern health care knowledge and processes to better fit care systems. Despite this apparent convergence of in- Indigenous health concepts, social arrangements and terest, governments carefully continue to define, with needs. Although health policies and official govern- or without an official policy, the sphere over which ment literature promotes this goal, the barriers associ- Indigenous People can exercise some influence de- ated with the contractual environment, especially with spite paying lip service to Indigenous self-government the ACCHS and Maori provider funding models, re- (Canada), Aboriginal self-determination (Australia) or main daunting. It is a postulate of this paper that pan- the Treaty of Waitangi (New Zealand). Indigenous comparative health research can inform

Journal of Aboriginal Health • January 2004 19 Lavoie policy development and implementation. To date, 6. Robert K. Yin, “Enhancing the quality of case studies in only one study has focused on Indigenous health ser- health services research,” Health Services Research, Vol. 34, (1999), p.1209-1224. Robert K. Yin, Case Study Research: vices financing with case studies from Australia, Nor- Design and Methods, Applied Social Research Methods Se- 99 way and Canada. International Indigenous health ries 5, (Thousand Oaks: Sage Publications, 1994). policy analysis has tended to focus on Australia and 7. Barbara McPake and Anne Mills, “What can we learn from the United States100 or Canada.101 More work is re- international comparisons of health systems and health sys- tem reform?” Bulletin of the World Health Organisation, quired to assess the impact of competitive (ACCHS, Vol. 78, (2000), p. 811-820. Maori providers) as opposed to relational (Health 8. The analysis is informed by an analytical framework based Transfer Policy, PHCAP) contractual environments in on the decision-space analysis developed by Thomas Bossert. providers’ ability to deliver effective services; evalu- Thomas Bossert, “Analyzing the decentralization of health systems in developing countries: Decision-space, innovation ate how contractual different arrangements may and performance, Social Science and Medicine, Vol. 47, favour or impede the implementation of Indigenous (1998), p. 1513-1527. models of health service delivery; and the extent to 9. Andrew Armitage, Comparing the Policy of Aboriginal As- which findings can be generalized to other countries. similation: Australia, Canada and New Zealand, (Vancouver: UBC Press, 1995). Augie Fleras and Jean Leonard Elliot, The ‘Nations Within’, Aboriginal-State relations in Canada, the ACKNOWLEDGMENTS United States, and New Zealand, (Toronto: Oxford Univer- sity Press, 1992). Paul Havemann, Indigenous Peoples’ The policy analysis presented here is part of a Rights in Australia, Canada and New Zealand, (Oxford: Ox- larger research project undertaken in partial fulfill- ford University Press, 1999). ment for a PhD with the London School of Hygiene 10. Stephen J. Kunitz, Disease and Social Diversity, the Euro- and Tropical Medicine Health Policy Unit. Although pean impact on the health of Non-Europeans, (New York: Oxford University Press, 1994). Frank Trovato, “Aboriginal the insights are my own, I am indebted to a large Mortality in Canada, the United States and New Zealand, number of people who have provided their time and Journal of Biosocial Sciences, Vol. 33, (2001), p. 67-86. support. The Foundation Alma and Baxter Ricard of 11. The specifics of national documents are explored in the case Canada funds the research. I would like to thank the studies. 12. On the topic, see Will Kymlicka, Multicultural Citizenship: A Australian National University National Centre for Liberal theory of minority rights, (Oxford: Clarendon Press, Epidemiology and Population Health, the Darwin- 1995). based Menzies School of Health Research, the 13. Examples abound. For Canada: see James B. Waldram, D. Massey University Te Punamawa Hauora in Welling- Ann Herring and T. Kue Young, Aboriginal Health in Canada: Historical, cultural and epidemiological perspec- ton, New Zealand, and the University of Manitoba tives, (Toronto: University of Toronto Press, 1995). For Aus- Centre for Aboriginal Health Research, Winnipeg, tralia: see Ralph Folds, Crossed Purposes: The Pintupi and Canada, for their support. A special thank you to my Australia’s Indigenous policy, (Sydney: UNSW Press, 2001). supervisors Lucy Gilson and Stephen Jan for their in- For New Zealand: see Mason Durie, Mauri Ora: The Dynam- ics of Maori Health, (Oxford: Oxford University Press, sightful comments on an earlier draft. 2001). 14. The Alma-Ata Declaration was adopted by delegates attend- ENDNOTES ing the World Health Organization-sponsored 1978 Interna- tional Conference on Primary Health Care in Alma-Ata, Rus- 1. Peter S. Hill et al., “Tactics at the interface: Australian Abo- sia. The resolution made a commitment to community-based riginal and Torres Strait Islander health managers,” Social and community-driven primary health care as the preferred Science and Medicine, Vol. 52, (2001), p. 467-480. mechanism to alleviate health inequalities. The Ottawa Char- 2. This figure includes 46 per cent of communities under the ter was adopted by delegates attending the First International Health Transfer Policy, 23 per cent under the Community- Conference on Health Promotion in Ottawa in 1986. The res- Based Health Services Agreements and two per cent under olution builds on the Alma-Ata declaration and reaffirms a the Self-Government Agreement for a total of 427 communi- commitment to community participation in primary health ties (2000 figures). care and health promotion. 3. Canada, Health Canada, Annual Report First Nations and 15. Peter Dobkin Hall, “A Historical overview of the private non- Inuit Control: Program Policy Transfer Secretariat and profit sector,” The Nonprofit Sector, A Research handbook, Planning Directorate, Health Funding Arrangements, (Min- Walter W. Powell, ed., (New Haven: Yale University Press, ister of Public Works and Government Services Canada, 1987). 2002). 16. H.B. Hansmann, The Ownership of Enterprise, (Cambridge: 4. New Zealand Te Puni Kokiri, Progress Towards Closing So- The Belknap Press of Harvard University Press, 1996). cial and Economic Gaps Between Maori and non-Maori, 17. The terminology adopted here has currency in international New Zealand Te Puni Kokiri, (2000). health system and economic literature. It defines the system 5. A Maori provider is defined as an independent Maori health in terms of role and money flow. The purchaser is often the organization with a Maori governance and management Ministry of Health. However, that role can be delegated to structure. health boards if they are fund holders given the task of pay-

20 Journal of Aboriginal Health • January 2004 Governed by Contracts

ing independent service providers like general practitioners. categories imply full status and Aboriginal rights. Children of Providers can be a medical practice, Indigenous health orga- parents classified as 6(1) are classified as 6(1). Children of a nization, private hospital, etc. They are contracted by the pur- 6(1) parent and 6(2) parent are classified 6(1). Children of a chaser to deliver specific services. Although the terminology 6(1) parent and a non-status are considered 6(2). Children of is at times associated to an ideological commitment I do not parents classified as 6(2) are considered 6(1). Finally, chil- subscribe to, and an approach that has not delivered the bene- dren of a 6(2) parent and non-status parent are considered fits anticipated, the terminology remains useful as it sepa- non-status and therefore the responsibility of the provinces. rated roles and clearly reflects asymmetries in power. See 27. Waldram, Herring and Young, Aboriginal Health in Canada. Geoff Fougere, “Transforming Health Sectors: New logics of 28. First Nations People continue to argue that access to free organizing in the New Zealand health system,” Social Sci- comprehensive health care is a treaty right. Access to health ence and Medicine, Vol. 52, (2001), p. 1233-1242. care was brought up in the negotiations of Treaties 6, 8 and 18. John Stewart, “New management relationships in the public 11. However, it was incorporated in the final text of Treaty 6 sector: The Limitations of government by contract, Public only, under the Medicine Chest Clause. The current federal Money and Management (July-September 1993), p. 7-12. government’s position stems from the 1966 Supreme Court 19. Peter Crampton, Anthony Dowell and Alistair Woodward, of Saskatchewan ruling on the Johnston case. It ruled that “Third sector primary care for vulnerable populations,” So- health care for First Nations is a matter of policy rather than a cial Science and Medicine, Vol. 53, (2001), p. 1491-1502. right and is subject to the whims of the Minister of Health. Richard G. Frank and David S. Salkever, “Nonprofit organi- Waldram, Herring and Young, Aboriginal Health in Canada. zations in the health sector,” Journal of Economic Perspec- 29. H.B. Hawthorn, A Survey of the Contemporary Indians of tives, Vol. 8, (1994), p. 129-144. Jack Needleman, “The Role Canada Economic, Political, Educational Needs and Poli- of nonprofits in health care,” Journal of Health Politics, Pol- cies Part 1, The Hawthorn Report (Indian Affairs Branch, icy and Law, Vol. 26, (2001), p. 1113-1130. Stephen Toll- 1966). man, “Community oriented primary care: Origins, evolution, 30. Sally M. Weaver, Making the Canadian Indian Policy: The application,” Social Science and Medicine, Vol. 32, (1991), Hidden Agenda, 1968-1970, (Toronto: University of Toronto p. 633-642. Press, 1981). 20. Frank and Salkever, “Nonprofit organizations in the health 31. Abu Nazier, Director, Health Funding Arrangements, Med- sector.” ical Services Branch, 1998, cited in Laurel Lemchuk-Favel, 21. Pan-Indigenous organizations such as tribal councils Financing a First Nations and Inuit Integrated Health Sys- (Canada), pan-iwi consortiums (New Zealand) and regional tem: A Discussion document (Ottawa, 1999). Aboriginal health boards (Australia) have emerged, not be- 32. Canada, Indian and Northern Affairs Canada, Aboriginal cause local governance is no longer relevant, but rather to ex- Self-Government: The Government of Canada’s approach to pand access to resources. implementation of the inherent right and the negotiation of 22. I am making what I think is an important distinction between Aboriginal self-government (Minister of Public Works and self-administration, being the administration of government- Government Services Canada, 1993). defined programs and other public tasks, and self-determina- 33. This policy appears to be moving forward slowly in the tion, which in the Indigenous literature invariably includes Yukon Territory and British Columbia. the power to define what relevant programs and tasks are and 34. Canada, Health Canada, Indian Health Policy 1979, Ac- how they should be delivered. cessed 2001, (Health Canada Medical Services Branch, 23. For Canada: Canada, Health Canada, Indian Health Policy 2000). 1979 (Accessed 2001), (Health Canada Medical Services 35. Lionel Bird and Meredith Moore, “The William Charles Branch, 2000). For Australia: National Aboriginal and Torres Health Centre of Montreal Lake Band: A Case study of trans- Strait Islander Health Council, National Aboriginal and Tor- fer, Arctic Medical Research Supplement, Vol. 50 (1-4), res Strait Islander Health Strategy, Consultation Draft, (1991), p. 47-49. (2001). For New Zealand: Annette King, The New Zealand 36. Canada, Health Canada, Transferring Control of Health Pro- Health Strategy (Ministry of Health, 2000). grams to First Nations and Inuit Communities, Handbook 1: 24. King George. (bloorstreet-com web services, 1763), 2002. An Introduction to all three approaches (Health Canada, Pro- 25. Ken Coates, “The ‘gentle occupation,’ The Settlement of gram Policy Transfer Secretariat and Planning Health Fund- Canada and the dispossession of the First Nations,” Indige- ing Arrangements, 1999). nous Peoples’ Rights in Australia, Canada and New Zealand, 37. These are services that Health Canada offers outside the um- Paul Havemann, ed., (Oxford: Oxford University Press, brella of Medicare (insured services) and have been made 1999). available free of charge (although terms of admissibility have 26. Specifically, from the turn of the last century until 1985, a been changing) to Status and Treaty Indians, and Inuit. In- First Nation woman who married a man who was not First digenous People argue that these services are an Aboriginal Nation lost her Indian Status. The same applied to children right entrenched in the Medicine Chest Clause of Treaty 6. from this marriage. In contrast, a non-First Nation woman However, the federal government argues that these services who married a First Nation man gained Indian Status. This are offered on humanitarian grounds. This position is sup- discriminatory provision was repealed from the Indian Act ported by the Johnston v the Crown Supreme Court ruling (in with the adoption of Bill C-31 in 1985. As the legislation appeal) of 1969, although more recent court cases, namely stands now, First Nations people who are descendents of a Sparrow and Sioui, indicate that this early ruling may not treaty signatory and never lost their Indian Status are eligible hold to more contemporary interpretations of treaty rights. to be registered as an “Indian” under the Indian Act article There is some experimentation currently occurring with Non- 6(1). Those who lost status by marriage or other discrimina- Insured Health Benefits Program. tory means prior to 1985 are eligible for registration under 38. Under the Integrated Community-Based Health Services the Indian Act article 6(2). Both 6(1) and 6(2) classification model (1994), First Nations can choose to sign one contribu-

Journal of Aboriginal Health • January 2004 21 Lavoie

tion agreement to administer selected community health ser- for better health (North Sydney: Allen and Unwin, 1991). vices. The self-government option provides an opportunity Two reports give a comprehensive overview of the impact of for First Nations to reconcile all federal government funding colonialism on Aboriginal People. Australia National Inquiry agreements under one framework agreement. Canada, Health into the Separation of Aboriginal and Torres Strait Islander Canada, Transferring Control of Health Programs to First Children, Bringing Them Home: Report of the National In- Nations and Inuit Communities, Handbook 1: An Introduc- quiry into the Separation of Aboriginal and Torres Strait Is- tion to all three approaches (Health Canada, Program Policy lander Children from Their Families (Commonwealth Gov- Transfer Secretariat and Planning Health Funding Arrange- ernment, 1997). Australian Council for Aboriginal ments, 1999). Reconciliation, Royal Commission on Aboriginal Deaths in 39. Pran Manga and Laurel Lemchuk-Favel, Health Care Fi- Custody (Australian Council for Aboriginal Reconciliation, nancing and Health Status of Registered Indians (Ottawa, 1998). These documents are available online. 1993). 49. Henry Reynolds, Aboriginal Sovereignty, Three Nations, One 40. John Eyles, Stephen Birch and Shelley Chambers, “Fair Australia? (St Leonards, New South Wales: Allen and Un- shares for the Zone: Allocating health care resources for the win, 1996). Henry Reynolds, “New Frontiers,” Indigenous native populations of the Sioux Lookout zone, Northern On- Peoples’ Rights in Australia, Canada and New Zealand, Paul tario, Canadian Geographer, Vol. 38, (1994), p. 134-150. Havemann, ed, (Oxford: Oxford University Press, 1999). 41. Canada, Royal Commission on Aboriginal Peoples, Volume 50. Tim Rowse, Indigenous Futures: Choice and development 3 - Gathering Strength. (Royal Commission on Aboriginal for Aboriginal and Islander Australia (Sydney: University of Peoples Royal Commission on Aboriginal Peoples - Final New South Wales, 2002). Report, 1996). Interestingly, this report merely reflected 51. These centres were initially called Aboriginal Medical Ser- Health Canada stated expenditure data and overlooked en- vices (AMS). This terminology is still widely used today. tirely the analysis by Manga and Lemchuk-Favel that had The contemporary term is Aboriginal Community Controlled been commissioned for the report. Health Services (ACCHS), which I use throughout the text. 42. Service delivery in the Far North is expected to be much 52. Max Kamien, “Cultural Chasm and Chaos in the Health Care more expensive than the rest of the country. It is not clear Services to Aborigines in Rural New South Wales,” Medical whether the figures include Métis and off-reserve First Na- Journal of Australia Special Supplement 2 (1975) p.6-11. tion Peoples. 53. A. Somjen, Chapter 3, “Distinguishing Features of Reform in 43. John W. Elias and Deanna J. Greyeyes, Report on an Envi- Australia and New Zealand,” Health Reform in Australia and ronmental Scan of Mental Health Services in First Nations New Zealand, Abby L. Bloom, ed. (Canberra: Oxford Uni- Communities in Canada for the Assembly of First Nations versity Press, 2000). (Prince Albert, Sask., 1999). 54. Keys Young, Market Research into Aboriginal and Torres 44. Laurel Lemchuk-Favel, Financing a First Nations and Inuit Strait Islander Access to Medicare and the Pharmaceutical Integrated Health System: A Discussion document (Ottawa, Benefits Scheme (1997). Ont., 1999). 55. Ben Bartlett et al., Central Australian Health Planning Study, 45. According to this recent ruling, Aboriginal People may have Final Report (PlanHealth Pty Ltd., 1997). Ben Bartlett and lost sovereignty and thereby must comply with Common- Pip Duncan, Top End Aboriginal Health Planning Study: Re- wealth and state legislations, but they may not have lost title port to the Top End Regional Indigenous Health Planning to (some of) their land, if continuous occupation can be Committee of the Northern Territory Aboriginal Health Fo- proven. rum (Plan Health Pty Ltd., 2000). 46. According to Henry Reynolds, frontier conflict was usually 56. David Scrimgeour, Community Control of Aboriginal Health small scale, but lasted a long time. He reports that between Services in the Northern Territory, Menzies Occasional Pa- 1788 and the 1920s, about 2,000 Europeans were killed com- pers, (Alice Springs, 1997). pared to 20,000 Aborigines. Oral histories collected by Debo- 57. Australia National Aboriginal Health Strategy Working rah Bird Rose and Richard Trudgen in the Northern Territory Party, A National Aboriginal Health Strategy (Canberra, suggest that the violence against Aborigines may have lasted 1989). National Aboriginal and Torres Strait Islander Health longer. Their work invalidates the popular Australian belief Council, National Aboriginal and Torres Strait Islander that Aborigines did not resist invasion. Henry Reynolds, Health Strategy, Consultation Draft (NATSIHC, 2001). “New Frontiers,” Indigenous Peoples’ Rights in Australia, 58. Australian Council for Aboriginal Reconciliation, Royal Canada and New Zealand, Paul Havemann, ed., (Oxford: Commission on Aboriginal Deaths in Custody (Australian Oxford University Press, 1999). Deborah Bird Rose, Hidden Council for Aboriginal Reconciliation, 1998). Histories: Black Stories from Victoria River Downs, Humbert 59. Australia Parliament of the Commonwealth of Australia, River and Wave Hill Stations (Canberra: Aboriginal Press Health is Life: Report on the inquiry into Indigenous health Studies, 1991). Richard Trudgen, Why Warriors Lie Down (House of Representatives, Standing Committee on Family and Die: Towards an understanding of why the Aboriginal and Community Affairs, 2000). People of Arnhem Land face the greatest crisis in health and 60. The movement has yet to be supported by a national health education since European contact (Darwin: Aboriginal Re- policy. The reason for this lies in the murkiness of the Aus- source and Development Services Inc., 2000). tralian health jurisdiction. ATSIC is responsible for monitor- 47. Lindsey Harrison, “Government Policy and the Health Status ing health delivery and advises the Minister for Aboriginal of Aboriginal Australians in the Northern Territory, 1945- and Torres Strait Islander Affairs on the effectiveness of 72,” Migrants, Minorities and Health: Historical and Con- strategies implemented by the Commonwealth Department of temporary Studies, Lara Marks and Michael Worboys, eds. Health, who assumed the administration of Aboriginal health (London: Routledge, 1997). in 1995. ATSIC has an official Aboriginal health policy. Its 48. Sherry Saggers and Dennis Gray, Aboriginal Health and So- influence on the Department of Health is defined in a memo- ciety: The Traditional and contemporary Aboriginal struggle randum of understanding and remains advisory. Australia

22 Journal of Aboriginal Health • January 2004 Governed by Contracts

Aboriginal and Torres Strait Islanders Commission, ATSIC 78. Durie, Whaiora: Maori health development. Health Policy (ATSIC National Policy Office, 2001). The 79. K. Wetere, Te Urupare Rangapu: Te Rarangi Kaupapa/Part- Northern Territory and states continue to generate their own nership Perspectives: A Policy Statement (Ministry of Maori Aboriginal health policies. Affairs, 1988). 61. Scrimgeour, Community Control of Aboriginal Health Ser- 80. Durie, Whaiora: Maori health development. vices. 81. The purchaser-provider split refers to the separation of the 62. Australia, Commonwealth Department of Health and Aged funder, purchaser and provider functions within the health Care, The Aboriginal and Torres Strait Islander Coordinated care system. Because of this approach, the government health Care Trials, National Evaluation Report Volume 1, Main Re- provider function (government-owned and -operated hospi- port (Australia Commonwealth Department of Health and tals, clinics and public health departments) become either pri- Aged Care and KPMG, 2001). Katherine West Co-ordinated vatized or sub-contracted to the non-profit sector. Govern- Care Trial Local Evaluation Team, Jirntangku Miyrta, ments retain a limited role of funder/purchaser and regulator Katherine West Coordinated Care Trial Final Report (Men- of services. Proponents of this approach hope for improve- zies School of Health Research, 2000). ments in performance and operational efficiency, a minimiza- 63. Australia Commonwealth Department of Health and Aged tion of conflicts of interests and increased responsiveness to Care Office of Aboriginal and Torres Strait Islanders Health consumer wants and needs because of the competitive mar- Services, Primary Health Care Access Program (OATSIH, ket-like environment. Andrew Podger, “Reforming the Aus- 2002). tralian Health Care System: A Government perspective,” 64. The term Maori is a prevalent, although contested, self-refer- Health Affairs (May/June 1999), p. 111-113. Sweden, the ent for the Indigenous population of New Zealand. Like the United Kingdom and New Zealand have adopted this ap- terms Aborigines and First Nations, Maori glosses over tribal proach. It resulted in “the overlay and interweave [of] market distinctions. mechanisms into largely publicly funded and publicly pro- 65. Malcolm Nicolson, “Medicine and Racial Politics: Changing vided health systems.” The result has been mixed. New images of the New Zealand Maori in the nineteenth century,” Zealand now appears to be shying away from this approach. Imperial Medicine and Indigenous Societies, David Arnold, (Geoff Fougere, “Transforming Health Sectors: New logics ed. (Manchester: Manchester University Press, 1988). of organizing in the New Zealand health system,” Social Sci- 66. Alan Ward and Janine Hayward, “Tino Rangatiratanga, ence and Medicine, Vol. 52, (2001), p. 1233-1242.). How- Maori in the political and administrative system,” Indigenous ever, the terminology still permeates the system. Peoples’ Rights in Australia, Canada and New Zealand, Paul 82. New Zealand Ministry of Health, Policy Guidelines for Re- Havemann, ed., (Oxford: Oxford University Press, 1999). gional Health Authorities, (New Zealand Ministry of Health, 67. The English version of Article 1 provides for a transfer of 1994). sovereignty to the British Crown. Article 2 ensures the con- 83. Durie, Whaiora: Maori health development. tinuation of property rights. Article 3 guarantees rights equal 84. Although competition was definitely the leading ideology, to other New Zealand citizens. The Maori translation of Arti- two measures were put in place in the HFA to ensure that cle 1 did not convey a transfer of sovereignty, but that of ad- Maori providers would be able to access health service deliv- ministrative authority (kawanatanga). Article 2 translated ery funding and compete with other providers. A first mea- “full and undisturbed possession” as tino rangatiratanga, sure was the creation of the Maori Provider Development which implies the full recognition of the authority of the Scheme. It is a proposal driven scheme that funds capacity chiefs. It also translated “other properties” as taonga katoa, and infrastructure development. A second measure was prac- which implies cultural as well as material properties. Durie, tice rather than policy based. It recognized Maori providers Whaiora: Maori health development. The full texts of the as preferred provider for contracts for which performance had Treaty, along with a transliteration of the Maori text, can be been satisfactory (Wayne McLean, Personal Communication, found at http://www.govt.nz/aboutnz/treaty.php3. 2003). 68. Ward and Hayward, “Tino Rangatiratanga, Maori in the po- 85. Both funding formula favour individual-focused interven- litical and administrative system.” tions rather than a whanau (family-centred) or hapu (sub- 69. Representatives were to be elected by Maori men, but could tribe, or community) approach favoured by Maori. Mason be non-Maori. Durie, Mauri Ora: The Dynamics of Maori Health (Oxford: 70. Armitage, Comparing the Policy of Aboriginal Assimilation. Oxford University Press, 2001). 71. M.P.K. Sorrenson, “The Settlement of New Zealand from 86. New Zealand Te Puni Kokiri, Maori Provider Views of Gov- 1835,” Indigenous Peoples’ Rights in Australia, Canada and ernment Funding, Key issues from the literature and inter- New Zealand, Paul Havemann, ed. (Oxford: Oxford Univer- views (2000). sity Press, 1999). 87. This is in addition to funding secured from other sources. 72. Derek A. Dow, Maori Health and Government Policy 1840- Minister of Health, Te Puni Kokiri, district health boards, etc. 1940 (Wellington: Victoria University Press, 1999). Durie, 88. New Zealand Ministry of Health. The Primary Health Care Whaiora: Maori health development. Strategy (New Zealand Ministry of Health, 2001). 73. Nicolson, “Medicine and Racial Politics.” 89. Mason Durie, Tribal Authorities as Advocates for Maori 74. New Zealand Waitangi Tribunal, Whanau o Waipareira Re- Health (New Zealand Board of Health, 1987). New Zealand port (Legislation Direct, 1998). Ministry of Health, 1994/95 Policy Guidelines for Maori 75. Toon van Meijl, “A Maori Perspective on Health and Its Poli- Health/Nga Aratohu Kaupapahere Hauora Maori (New tization,” Medical Anthropology, Vol. 15, (1993), p. 283-297. Zealand Ministry of Health, 1994). New Zealand Ministry of 76. New Zealand Ministry of Health, Hui Whakaoranga: Maori Health, 1995/96 Policy Guidelines for Maori Health/Nga health planning workshop, Hoani Waititi Marae, March 19- Aratohu Kaupapahere Hauora Maori (New Zealand Min- 22, 1984. New Zealand Ministry of Health, 1984. istry of Health, 1995). New Zealand Ministry of Health, 77. Durie, Whaiora: Maori health development. 1996/97 Policy Guidelines for Maori Health/Nga Aratohu

Journal of Aboriginal Health • January 2004 23 Lavoie

Kaupapahere Hauora Maori (New Zealand Ministry of icy in Australia (Melbourne: Oxford University Press, 1997). Health, 1996). Stephen Jan, “How Much Should We Be Spending on Health 90. New Zealand Ministry of Health, He Korowai Oranga, Services for Aboriginal and Torres Strait Islander people?” Maori Health Strategy: Discussion Document (New Zealand Medical Journal of Australia, Vol. 169 (1998), p. 508-509. Ministry of Health Discussion paper, 2001). Peter Markey, “Internal Markets and Aboriginal Health,” 91. A Maori Provider Development Scheme was established in Australian and New Zealand Journal of Public Health, Vol. 1997. It is funded at $10M NZ per year. Access to funds is 21, (1997), p. 343. Robyn McDermott, “Improving Equity proposal driven with annual allocations. Funds are available and Efficiency in the Bush: A Needs-based method for for infrastructure, workforce and service developments, best healthcare resource allocation in remote communities,” Aus- practice and procedures manuals, and scholarships. tralian Journal of Rural Health, Vol. 3, (1995), p. 72-79. 92. Durie, Mauri Ora. Robyn McDermott, “Aboriginal Health Spending: More 93. Toni Ashton, “Contracting for Health Services in New needed, but where?” Australian and New Zealand Journal of Zealand: A Transaction cost analysis,” Social Science and Public Health, Vol. 22, (1998), p. 637-638. Gavin Mooney, Medicine, Vol. 46 (1998) p. 357-367. “Funding for Aboriginal Health Care: The Case for a new ini- 94. It includes treatment and rehabilitative care if it is within the tiative,” Australian and New Zealand Journal of Public scope of the on-reserve system. Otherwise, the patient is Health, Vol. 20, (1996), p. 564-565; Gavin Mooney, “Re- transferred to the nearest referral centre. source Allocation and Aboriginal Health,” Australian and 95. Laurence Malcolm et al., The development of Primary Health New Zealand Journal of Public Health, Vol. 20, (1996) p. 9. Care Organisations in New Zealand (New Zealand Ministry Gavin H. Mooney, “What’s Fair in Funding Indigenous of Health, New Zealand Treasury, 1999). Health Care? We don’t know, but isn’t it time we did?” The 96. Assembly of First Nations, Presentation Notes to the Com- Drawing Board: An Australian Review of Public Affairs, Vol. mission on the Future of Healthcare in Canada (Assembly of 1, (2000) p. 75-85. Gavin H. Mooney and Virginia L. Wise- First Nations, 2002). Dara Culhane Speck, “The Indian man, “How Much Should We Be Spending on Health Ser- Health Transfer Policy: A Step in the right direction, or re- vices for Aboriginal and Torres Strait Islander People?” Med- venge of the hidden agenda?” Native Studies Review, Vol. 5, ical Journal of Australia, Vol. 168, (1998), p. 508-509. (1989), p. 187-213. Durie, Whaiora: Maori health develop- Gavin Mooney, Stephen Jan and Virginia Wiseman, Chapter ment. 13, “Economic Issues in Aboriginal Health Care,” Economics 97. Ian Anderson, Chapter 10, “The Ethics of the allocation of and Australian Health Policy, Gavin Mooney and Richard health resources,” Race Matters: Indigenous Australians and Scotton, eds. (St. Leonards, New South Wales: Allen and Un- ‘Our society,’ Gillian Cowlishaw and Barry Morris, eds., win, 1998). Komla Tsey and David Scrimgeour, “The Fun- (Canberra: Aboriginal Studies Press, 1997). Australia Abo- der-Purchaser-Provider Model and Aboriginal Health Care riginal and Torres Strait Islanders Commission, Resourcing Provision,” Australian and New Zealand Journal of Public Indigenous Development and Self-Determination (Australia Health, Vol. 20, (1996), p. 661-664. Institute, 2000). Australia Commonwealth Department of 98. John D. O’Neil, Jeffrey R. Reading and Audrey Leader, Health and Aged Care, The Quality of Australian Health “Changing the Relations of Surveillance: The Development Care: Current issues and future directions, Occasional pa- of a discourse of resistance in Aboriginal epidemiology,” Hu- pers: Health financing series, Vol. 6. (Canberra, 2000). Aus- man Organization, Vol. 57, (1998), p. 230-237. tralia Commonwealth Department of Health and Aged Care, 99. David Scrimgeour, “Funding for Community Control of In- Submission to the Commonwealth Grants Commission’s In- digenous Health Services,” Australian and New Zealand quiry into Indigenous Funding (Commonwealth Department Journal of Public Health, Vol. 20, (1996), p. 17-18. of Health and Aged Care, 2000); Australian Institute of 100. Stephen J. Kunitz, and Maggie Brady, “Health Care Policy Health and Welfare, Expenditures on Health Services for for Aboriginal Australians: The Relevance of the American Aboriginal and Torres Strait Islander People 1998-1999, Indian experience,” Australian and New Zealand Journal of HIHW Catalogue No. IHW 7 (2001). C.B. Burns et al., “Re- Public Health, Vol. 19, (1995), p. 549-558. Stephen J. Ku- source Requirements to Develop a Large, Remote Aboriginal nitz, “Public Policy and Mortality Among Indigenous Popu- Health Service: Whose responsibility?”Australian and New lations of Northern America and Australasia,” Population Zealand Journal of Public Health, Vol. 22, (1998), p. 133- and Development Review, Vol. 16, (1990), p. 647-672. 139. J. Deeble, J.et al., Expenditures on Health Services for 101. Greg Crough, “Indigenous Organisations, Funding and Ac- Aboriginal and Torres Strait Islander People, AIHW Cata- countability: Comparative reforms in Canada and Australia,” logue No. HWE 6 2225 (1998). Health Gardner, Health Pol- NARU Report Series No. 2, (1997).

24 Journal of Aboriginal Health • January 2004