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One Nation, Two Healthcare Systems




The Canadian medical system has integrated several
paradigm-shifting transformations in the past two decades, not the least of
which include quality improvement a nd patient-centred c are. With each
transformation there has been a concurrent benefit to patients, leading to
improved patient outcomes and more effective systems of care. In this context
it would be reasonable to then ask, why are Canadian Indigenous patients so
sick?

Canadian Indigenous patients—those of First Nations, Metis
and Inuit descent—continue to suffer much higher rates and severity of disease
when compared to other demographics. HIV rates on Saskatchewan reserves are higher
than many African nations. Infants in Nunavut suffer the highest rates of
respiratory disease in Canada. The incidence of diabetes is three to five times
higher. Itis factual that significant health disparities exist between Indigenous
patients and other Canadian demographics. We are also observing that these
disparities are not static. In many areas they are widening and in some cases
accelerating.



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Analysing the causes behind this ongoing health crisis have
taken us in many different directions. More recently, the Social Determinants
of Health have provided a useful context to frame these causes into poverty,
education, early childhood development, food insecurity, racism, among others
(Mikkonen and Raphael 2010). As health leaders however, it is difficult to
reconcile how to impact areas clearly out of our scope of influence. For
example, how does a health leader impact poverty from within the confines of
the health system?

Taking a systems approach can have much more utility. In
Canada, there are actually many different types of health systems. The most
well-known is Medicare, a system funded by both federal and provincial levels of
government but administered by each respective province. Lesser known health
systems include those both federally-funded and administered. These include refugee
health, the military, the prison system and indigenous health. Despite the
oft-repeated statement that providing healthcare is a provincial
responsibility, the federal government clearly is very much in the business of
healthcare.

When comparing the design of all these various health systems,
there are some surprising insights. In Medicare, various types of legislation
create accountabilities that enable patient rights. The Health Acts of each
province establish a baseline of services that must be provided: services such
as emergency care, laboratory services, diagnostic imaging, among others. Other
acts include those that govern health quality, health professions, etc. Legislation
creates fiduciary duty. Fiduciary duty necessitates defined processes.

None of these Acts exist federally. Without legislation, it
is difficult to create clear fiduciary duties and define processes. Many
federal programmes are thus dependent on policy; in many cases this is very
wellwritten. For example, the military health system has overcome the
legislative gap regarding health professions by establishing contractual
relationships with Colleges of Physicians and Surgeons across Canada. Recognising
that it would be unreasonable to create an independent regulatory framework to
govern health professionals within the federal military system, the military system
has created a workaround. Other legislative gaps are overcome in a similar
manner with the other federally-administered systems of care. Not so with
indigenous health.

There is no baseline of healthcare services on reserves. Instead
the Indigenous health system exists as a collection of various time-limited
funding proposals, usually selected from an à la carte buffet of programme
options. Instead of 24/7 coverage, we discuss “doctor days” and “nursing days.”
The system purposely schedules lack of access to medical professionals. For this
reason, access can fluctuate widely between indigenous communities. Consider
having no access to healthcare providers as an expected component of health
system design.

Credentialing, quality improvement, resuscitative equipment,
emergency medication, continuity of care, as well as the many other health
system components we take for granted are also very inconsistent. How can a health
system be built without the proper building blocks?

Canada is in the midst of a broad reconciliation process
with its indigenous peoples, triggered through a court-mandated Truth and
Reconciliation Commission that published its final report in 2015. Regarding
health transformation, National Chief Perry Bellegarde of the Assembly of First
Nations states: “the Truth and Reconciliation Commission Calls to Action
on health create a pathway for innovation and collaboration that will transform
healthcare and improve the health of First Nations people in Canada. This is
about supporting First Nations’ priorities based on our health care realities,
and finding solutions that draw on the effectiveness of our knowledge and
cultural traditions.”

To understand indigenous health realities we can start with
acknowledgement that indigenous patients may be sick because we literally
aren’t providing them the same healthcare as the rest of Canada.

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