Partnerships make up for health transfer shortfalls

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After taking the white man's medicine for 500 years, many First Nation communities are taking steps toward prescribing their own.

For more than 10 years, First Nations have been slowly assuming control of federal health care services delivered to their people.

It's hoped greater command of how federal dollars are spent - and programs and services delivered - on reserve will lead to an improvement in the health status of First Nations people.

"First Nations people are to some degree tired of having their lives run by other people and this was a chance to do it on their own," said Clare McNab, director of health for the Federation of Saskatchewan Indian Nations.

The federal government initiated the devolution of health care in the 1980s, when it decided to get out of providing many services and began looking at what it could download.

Health care seemed a natural fit after observing Indian and Northern Affairs Canada transfer education programs to First Nations as the latter moved toward self government.

"It was felt that where gains had been made (by the federal government) in the health status of First Nations, further gains would best result from the local level," said Dean Norton, regional program transfer manager with the medical services branch of Health Canada.

That's because First Nations are closer to their members and are more conscious of their specific health and cultural needs, said McNab. They also tend to be more successful at recruiting First Nations staff, who are better equipped - culturally and linguistically - to communicate with patients.

"A governmental approach has not been beneficial and has not addressed the needs of First Nations," added Ernest Sauve, director of health and social development for the Prince Albert Grand Council. "In any of the services, whether it be education or health, there's definitely a need to remove that dependence on governmental systems and promote First Nation involvement in their own development and autonomy."

Transferring responsibility for health services from the federal government to the band level is a long process, involving a tremendous amount of work by First Nations and tribal councils willing to take it on.

The first step is conducting a needs assessment of the community to determine what the health priorities are. This information forms the basis of a health plan, which outlines what services are to be transferred and how the First Nation proposes to deliver them.

As the whole process is voluntary, Norton says it's at this stage First Nations often decide if they're ready to assume responsibility for health care.

Norton added that some First Nations that have treaties with the federal government have refused to become involved at all, forcing Ottawa to find another way to deliver programs. Others simply aren't ready.

"First Nations are at different stages in terms of their own evolvement and development, and we just have to recognize that and encourage and support them at whatever pace they're going," said Sauve.

Once a plan has been drafted, Health Canada evaluates it to see if it has the mandatory programs such as communicable disease control, environmental health and treatment services, and represents a good public health plan. If the government is satisfied, negotiations on a health transfer agreement begin.

"By this time calling this process a negotiation is a misnomer because we don't have much flexibility in how much money we can put on the table" or the programs that can be taken over, said Norton.

Between $140 to $145 million a year is available for First Nation health care in Saskatchewan.

Like many agencies that provide health care, funding is a major complaint of First Nations. The federal government hasn't made provisions for cost-of-living increases or changes in population, said Pat Cook, assistant director of health and social development for the Prince Albert Grand Council.

For example, the grand council saw the combined population of ts 12 First Nations increase by more than 1,000 people a year - or close to 39 per cent - from 1991 to 1998. That's an increase of 7,419 people in seven years, or to 26,654 from 19,235.

This has forced the grand council, which administers community-based health care to some of its member First Nations and second-level services to all of them, to find ways to stretch its federal health care dollars farther. (Community-based health services include addictions, youth programs, home care and nursing. Second-level services include supervisory positions.)

The grand council is using a dispute resolution clause in its health transfer agreement, signed in 1992 and renewed in 1997, to bring this issue to the government's attention.

In the meantime, partnerships have become an alternative source of funding for First Nations. The grand council receives around $66,000 a year from the Prince Albert Health District for a diabetes educator and nutritionist.

The third phase of the transfer process involves implementing the agreement. This is often the most difficult stage, said Norton, as many First Nations must build an organization and develop the human resources necessary to administer these programs.

A variety of service delivery models have been developed, depending on the capacity of the First Nation involved. Some First Nations take it all on, offering both community-based and second-level services to its members.

Others opt only for community-based services, signing agreements with tribal councils for second-level services.

Some tribal councils like the Prince Albert Grand Council do community-based services for some of their member First Nations while administering second-level services to all of them.

Not all federal health care services are currently available for transfer.

Health facilities, consultation, bursaries and scholarships to aboriginal peoples, Canada Prenatal Nutrition Program development funds and the non-insured health benefits program are excluded and reprsent half of all First Nation health care spending.

However, plans are afoot for First Nations to take over regional and national Health Canada services. Pilot projects are also under way to determine if some non-insured health benefits can be transferred in the future.

The Prince Albert-based Northern Inter-Tribal Health Authority is in the midst of a study to determine if it wants to take over regional or national level services, said Norton.

Health authority officials were not available for comment.

It could take several more years before the transfer process is complete in Saskatchewan. Few First Nations in the south have taken over health services, says Norton, while northern First Nations and tribal councils are far advanced in the process.

The federal government will be monitoring health transfers over the next two to four years, but Norton doesn't expect services to ever be fully transferred.

McNab is not so sure.

"I think there will come a time when the federal government will have very little to do with First Nation communities," she said.