Jurisdiction And First Nations Health and Health Care Catherine L. Cook, MD, CCFP Thesis Submitted to the Faculty of Graduate Studies In Partial Fulfilment of the Requirements For the Degree of MASTER OF SCIENCE Department of Community Health Sciences Faculty of Medicine University of Manitoba 'Winnipeg, Manitoba @ copyright October, 2003 THE TINTYERSITY OF MANITOBA FACULTY OF GRADUATE STIIDIES ***** COPYRIGHT PERMISSION PAGE Jurisdiction and First Nations Health and Health Care BY Catherine L. Cook A ThesislPracticum submitted to the Facultv of Graduate Studies of The Universitv of Manitoba in partial fulfillment of the requirements of the degree of MASTER OF SCMNCE CATHERINE L. COOK @2003 ¡ Permission has been granted to the Library of The University of Manitoba to lend or sell copies of this thesis/practicum, to the National Library of Canada to microfi}n this thesis and to lend or sell copies of the fÏlm, and to University Microfilm Inc. to publish an abstract of this thesis/practicum. The author reserves other publication rights, and neither this thesis/practicum nor extensive extracts from it may be printed or otherwise reproduced without the author's written permission. ABSTRACT Research indicates that the health of Aboriginal people is improving; however, there continues to be a significant gap between the health status of First Nation peoples and the health status of all other Canadians. Several determinants of health contribute to differences in health status. and the use ofhealth services and access to these services are determinants that are important for the health status of First Nation peoples. There are many reasons for variations in the delivery of health care. Ambiguity in defining government level responsibility for health service delivery is hypothesised to have a negative impact. Compounding these effects is the direct conflict between stakeholders at each level involving jurisdictional responsibilities, the sharing of resources, and the perpetuation of existing structures. This study documents the health care delivery systems providing services for First Nation peoples, and reviews factors influencing access to health services within a historical and contemporary policy context. A review of relevant policy documents and archival materials is carried out to document how jurisdictional issues at the federal and provincial government levels have affected First Nation peoples ability to access or to deliver service. Key informant interviews with policy-makers and health care professionals were used to document their perspectives on jurisdiction. These ethnographic case studies examined real or perceived barriers in access to service or gaps in service for First Nation peoples, and the relationship to jurisdictional issues. This study has identified outstanding issues in jurisdiction, and some potential reasons why resolution of this jurisdictional ambiguity has not occurred. Key informant perspectives and policy document review have acknowledged the critical effects of jurisdictional ambiguity and its resultant outcomes on the health status of First Nation peoples. Resolution of jurisdictional issues in health care and social programming is a key factor for the enhancement of health status of First Nation peoples. -11 - ACKNOWLEDGEMENTS I would like to gratefully acknowledge and thank my thesis advisory committee members. My sincere appreciation is expressed to Dr. Joseph Kaufert, to Dr. Brian Postl, and to Dr. Sharon Macdonald for their patience, their support and their encouragement. I would like to thank the Health Information and Research Committee (HIRC) of the Assembly of Manitoba Chiefs for their support in this study. The assistance of Doreen Sanderson, Policy Analyst with the Assembly of Manitoba Chiefs who acted as an advisor for the studv as a member of the HIRC. was most helpful. I am grateful to my family and my colleagues for their support and encouragement over the last few years during which I was involved in this thesis. -111- TABLE OF CONTENTS Abstract.... ...................... i Acknowledgements ..... iii List of Figures.............. ................. vii List of Tables ............ ................... viii List of Appendices ....... ix Executive Summary.. .......................x CHAPTER 1 - INTRODUCTION Background: Policy and Health Services Development..............................3 Impact of Federal Assimilation Policies ..................7 Future Challenges ................8 1.1 Objectives ........11 I.2 Theoretical Framework: Health Services for First Nation Peooles ..........12 CHAPTER 2 _ LITERATURE REVIEW 2.1 Population Context of First Nation Peoples in Canada and Manitoba......15 2.2 First Nations Health Status ..................17 2.2.1 Premature Mortality Rate.......... .................19 2.2.2 Life Expectarrcy .......................21 2.2.3 Potential Years of Life Lost.......... .............23 2.3 The Historical Context for Health Care in Canada - all Canadians and First Nations - Legislation, Policy Development and Service Delivery............27 2.3.1 Legislative Background............... ..............27 2.3.2 Evolution of Health Service Delivery... .....30 2.3.3 Development of Universal Health Care.......... .............31 2.3.4 A Federal./Provincial Approach .................34 2.3.5 Federal Policy Deve1opment.............. ........35 2.3.6 The Legacy of Unresolved Jurisdictional Issues .........38 a/l L.a Jurisdiction for First Nations Health....... ...............41 2.4.1 Federal,/Provincial Jurisdiction in First Nations Public Health......42 2.4.2 The Indian Act vs. the Constitution Act in Health Jurisdiction .....45 2.4.3 Policy in First Nations Health....... .............47 2.4.4 Implications for First Nations Health Care in Manitoba ...............49 2.5 First Nations Health Issues ..................52 -lV- 2.6 First Nations Health Transfer.... ...........55 2.6.I Policy Framework ....................55 2.6.2 Community Profiles .................56 2.6.3 Planning Phases .....58 2.6.4 Infrastructure and Resources. .....................59 2.6.5 Evaluation ..............60 2.6.6 Evaluation - Key Issues of Contention............ ............60 Process ...................61 Role Clarity for Federal Government and First Nations Post-transfer................ .............62 'Residual Role' of the Federal Government ................64 2.6.7 Altematives to Health Transfer.... ..............65 2.7 Public Health Services .......66 2.8 Summary of Literature Review... .........68 CHAPTER 3 - STUDY METHODOLOGY 3.1 Methods.... ........69 3.2 Ethnography............... ........7I 3.3 Key Informants Interviews ........... .......73 3.4 Interview Process ...............75 3.5 Interview Analysis .............76 3.6 Data Trustworthiness .........77 3.7 Ethical Considerations.......... ...............79 3.8 Interviewers Perspective............ ..........81 3.9 Biases & Limitations ........... ................85 3.9.1 Biases .....................85 3.9.2 Limitations................ ...............85 CHAPTER 4 -FINDINGS AND DISCUSSION 4.I Jurisdictional Ambiguity............. .........88 4.I.1 Colonialism and Historical Perceptions of Aboriginal Peoples.....90 Assimilation Policies ...............92 Policy Development for First Nations ............. ............97 4.1.2 Aboriginal (First Nations) Rights ............100 Land C1aims................ ...........100 Self-govemment and Health Transfer.... ....................101 Fiscal Responsibi1ity............ ....................102 First Nations and Aboriginal Peoples - Canada's Commitments................ ........105 4.1.3 Access to Service ...................106 Public Health Services for First Nations..... ...............108 Primary Health Care Services.............. ....115 Primary Health Care Models .............. .....I17 A' -.L Jurisdictional Responsibility in First Nations Health Care......................I2I 4.2.1 Barriers to Service in First Nations Health Care .........................125 4.2.2 Fiscal Responsibility............ ....................130 The 'Insured Health Services' .................131 The 'Non-insured Health Benefits' ..........134 Non-insured Health Benefits - Financial Implications and Utilization Rates......... ............136 Non-insured Health Benefits - Restraints .................138 +.J Rationale and Strategies for the Resolution of Jurisdictional Issues .......146 4.3.1 Rationale ..............146 4.3.2 Strategies.. ............147 CHAPTER 5 - SUMMARY OF FINDINGS AND CONCLUSIONS 5.1 Summary of Findings .......151 5.1.1 Jurisdictional 4mbiguify.............. ............152 5.1.2 Colonialism and the Historical Perceptions of Aboriginal People ..............152 5.1.3 Aboriginal (First Nation) Rights....... .......153 5.1.4 Access to Service ...................154 5.1.5 Jurisdictional Responsibi1ity........ ............156 5.1.6 Barriers to Service.. ................156 5.1.7 Financial Responsibility ........... ...............157 5.2 Conc1usions................ ......159 5.2.1 Significance of the Study........ .................159 5.2.2 Conc1usions................ ............159 -vl- LIST OF FIGURES 1. Framework for Health Service in Manitoba .............. .............I2 2. Population Distribution of First Nations and Canadians ..........................15 a J. Population Profile of Registered First Nations in Manitoba, 1998............16 T. Infant Mortality .................20 5. Premature Mortality Rates ..................21 6. Life expectancy - Males .....................22 .7 Life expectancy