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 health services “for Indigenous People by Indigenous INDIGENOUS SECTORS: 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