1. First Nations and Inuit and the Canadian Health System
Keith Conn,
Chief Executive Advisor,
First Nations and Inuit Relations,
First Nations and Inuit Health Branch, Health Canada
Roma in an Expanding Europe
June 30 – July 1, 2003, Budapest, Hungary.

2. Overview Profile of First Nations and Inuit in Canada
Health Status of First Nations and Inuit
Socio-Economic Impacts on Health
Health Care Responsibilities
First Nations and Inuit Health Branch (FNIHB): Key Objectives
Historical Context of First Nations and Inuit Health Care
FNIHB: Structure, Programs and Resources
Early Childhood Development
Telemedicine
Working Towards Reconciliation
National and Regional Partnerships
National Aboriginal Organisations
What We’ve Learned
Contacts

3. Who are the Aboriginal peoples of Canada?
Descendants of the original inhabitants of North America
Canadian Constitution Act, 1982, recognizes
three groups of Aboriginal peoples:
1. Indians
2. Métis
3. Inuit
Challenge:
Metis people challenge the federal government to provide services for them.
Source 2001 Census Aboriginal identity Population
Status
Indians
On-Reserve
274,215
Status
Indians
Off-Reserve
283,960
Métis
292,305
Inuit
45,075

4. First Nations & Inuit Population
NIHB Eligible Population 721,086
(March 2002)

5. Consider the demographics…
Rate of population growth compared to rest of Canada
4½ X
Median Age difference with non-Aboriginal population
First Nations:14 years
Inuit: 17 years
Population under 20 years
of age
> 40 %
Challenge: Service needs of a young population living in rural and remote areas are very different from those of the general population
Canada’s First Nations population is growing at a rate of over 3% per year, more than four times the Canadian rate. (NOTE: this figure reflects the growth between the 1996 and 2001 Census and is not all to be attributable to birth rate and is based on self-reported identity. The Canadian population grew at 3.4%; Inuit at 12.1%; Metis at 43.2% and North American Indian at 15.1%.)
The Aboriginal population is younger, on average than the rest of the Canadian population. In 2001, the difference was about 14 years for First Nations and 17 years for Inuit. Compared to the non-Aboriginal population, the proportion of Aboriginal children under five years of age (for every 1,000 women of child-bearing age) was 70% greater for Aboriginal peoples. (Statistics Canada 1999)
Geography is a determinant of health. People in rural and remote communities have poorer health status than Canadians who live in larger centres. Access to health care also is a problem, not only because of the distances, but because these communities struggle to attract and keep nurses, doctors and other health care providers.
In the northern communities, the problems are exasperated. About 16,000 people live in the most northern part of Canada, at degrees north latitude (northern parts of Yukon, Northwest Territories and Nunavut). About two-thirds of them live more than 100km from a physician. And no physicians normally live above 70 degrees north latitude to serve the 3,300 people living there. (Ng et al, 1999)
Nursing shortage - 42% vacancy rates in nursing stations - increased costs of overtime, hiring through agencies, recruitment (approx. $35K to hire a single nurse), mandatory training costs.
In 1997/98, there were almost 2,000 qualified Aboriginal health care workers in Canada, including 800 nurses and 67 doctors. This makes up less than 1% of the health care providers in Canada, far lower than the proportion of Aboriginal peoples to the general population.
Live outside
of urban areas
First Nations: 57%
Inuit: 73%
First Nations communities with 1000 inhabitants or less
82 %

6. Health Status of First Nations & Inuit
Gap in life expectancy
6.3 years
50% higher
Rate of infant Mortality
7.2%
% of all AIDS cases in Canada
10 X
Rate of Tuberculosis
Rate of Heart Disease
and Diabetes
3 X
Suicide
and self-injury
Challenge:
First Nations and Inuit health needs are more urgent and important.
There are significant disparities in health outcomes between First Nations and the general population.
In 2000, the gap between life expectancy of registered First Nations people and other Canadians was estimated at 7.4 years for men and 5.2 years for women. (INAC 2002). Life expectancy reflects a number of determinants, including educational, social and economic status, as well as the performance of the health system.
Infant mortality is nationally and internationally accepted as a marker of both child well-being and population health. Infant mortality is influenced by a host of factors such as safe water supply, sanitation, proper nutrition, unpolluted living conditions, the control of diseases, availability of preventive health care and access to adequate health services.
The general health status of Aboriginal peoples is better today than it was 50 or even 10 years ago primarily because of noticeable improvements in living conditions and continued investments in disease prevention and public health. However, there remains significant gap in health status between First Nations and Inuit compared to the general population.
AIDS cases for First Nations and Inuit represent over 7% of all cases in Canada. The number of AIDS case amongst FNI has increased steadily since 1984, particularly amongst women.
As of 1999, the rate of Tuberculosis is 10 time that of the general population (FNIHB Statistical Profile)
As of 1999, the rate of Heart Disease and diabetes is 3 time that of the general population
Leading cause of
deaths for youth
Higher incidence of health problems among Aboriginal people, compared to the general population

7. Leading Causes of Death among First Nations and Inuit (by Sex), 1999
The 1999 crude death rate for First Nations males was deaths per 100, 000 population – 1.3 times the rate for First Nations females of
The difference between the sexes in death rate is largely attributable to higher rates of death among males caused by:
Injury and poisoning (322 deaths / 100,000 population)
Circulatory disease (97.5 deaths per 100,000 population)
Cancer (57.9 deaths per 100,000 population)
The leading causes of death among First Nations females in 1999 were:
Circulatory disease (72.2 deaths per 100,000 population)
Injury and poisoning (67.6 deaths per 100,000 population)
Cancer (59.8 deaths per 100,000 population)
First Nations females were far more likely to die from diabetes (26.8% higher than males).
Approximately 2/3 of all First Nations persons diagnosed with diabetes are female.

8. Leading Causes of Death among First Nations and Inuit (by Age), 1999
Age 20 to 44
Suicide and Self
Inflicted Injury %
Motor Vehicle
Traffic Accidents 15%
Homicide %
Accidental Poisoning
by Drugs %
Drowning and
Submersion %
Other %
Age 1 to 9
Fire and Flames 26%
Motor Vehicle
Accidents %
Other Injuries %
Other %
Age 10 to 19
Suicide and Self Inflicted Injury 38%
Motor Vehicle Accidents %
Drowning and Submersion 10%
Other %
For each age group 0-4 to 65+ the First Nations death rate is higher than the corresponding Canadian rate.
The largest difference is in the age group, where the First Nations rate is almost 4x that of the Canadian rate. For children through to adults aged 44, the most common causes of death were injury and poisoning.
For children, these deaths were classified as non-intentional.
By contrast in youth and early adults, the causes of injury and poisoning were most commonly intentional – suicide and self-injury accounted for 38% of deaths in youth and 23% of deaths in young adults.
In addition, 7% of deaths in early adults were homicides.
Age 45 to 64
Ischemic Heart Disease 17%
Lung Cancer %
Motor Vehicle Traffic
Accidents %
Diabetes %
Liver Disease and
Cirrhosis %
Other %
Age 65+
Ischemic Heart Disease %
Other Forms of Heart Disease 9%
Cerebrovascular Disease %
Lung Cancer 7%
Pneumonia and Influenza 6%
Other %
Legend:
N = number of deaths

9. Annual Number and Percentage of Aboriginal AIDS Cases 92-01
The proportion AIDS cases among Aboriginal People rose from 1% of all cases in Canada in 1990 to 7% in 2001.
It is extremely important that trends of HIV transmission and new infections are monitored closely, especially among high-risk populations, such as the Aboriginal people in Canada.

10. Socio-Economic Impacts on Health: First Nations and Inuit Educational Attainment, 1996
First Nations have historically had lower secondary school completion rates than other Canadians.
Improvement is occurring: in , 37% of First Nations children remained in school until grade 12; by , this figure had risen to 74%.
The precise reasons for this are unknown, but a number of factors are suspected:
The number of band-operated schools increased by 54% from to
Federal funding for education rose from $109 Million in to $280 Million in
Aboriginal Studies Programs (College / University level) expanded to more than 13 universities as of 1980
Post-secondary enrolment rates among First Nations and Inuit are lower than those among other Canadians: From to , the First Nations and Inuit post-secondary enrolment rate was 6-7% of year-olds, compared with 11-12% of year-old Canadians.
The first fully accredited Aboriginal University in Canada was established in June 2003.

11. Socio-Economic Impacts on Health: First Nations and Inuit Employment, 1996
Canadians in the lowest income quintile were four times more likely than Canadians in the higher income quintiles to report their health as either poor or fair in 1999.
In the three basic indicators – labour force participation rate, employment rate, and unemployment rate, First Nations people fare significantly more poorly than the general Canadian population:
The 1996 labour force participation rate for the Canadian population (68%) was 1.3 times higher than that for the on-reserve First Nations population (59%).
The disparity was greater on an age-specific basis, with the largest gap between First Nations and other Canadians between the ages of years of age being above 30%.
The gap between employment rates of First Nations people (43%) and other Canadians (60%) in 1996 was considerably wider at 19 points than labour force participation rates at 9%.
The 1996 First Nations unemployment was almost 3x higher than the Canadian rate.

12. Delivering Health Care is a Shared Responsibility
Federal Government
Provincial
& Territorial
Governments
First
Nations
& Inuit
Challenge:
To integrate the provincial/territorial and federal systems effectively to avoid overlap and eliminate gaps in health care delivery.
Funding for Aboriginal health services is shared between federal, provincial and territorial governments and Aboriginal organizations.
Studies suggest that the problem is not the level of funding for health care services but rather the fragmentation of funding, which in turn leads to poorly co-ordinated programs and services.
Through collaboration, we will eliminate gaps and redundancies leading to higher quality services

13. Federal Responsibilities
Delivery of primary health care and community health services on-reserve
Insurance coverage of drug, dental, vision and medical transportation for all Status Indians and Inuit
Targeted programs for all Aboriginal people, regardless of residency (Aboriginal Diabetes Initiative, Tobacco Control Strategy)

14. Provincial / Territorial Responsibilities
Provide access to universal hospitalization and physician services to all residents including Aboriginals
Community health programs for people off-reserve including Aboriginals
Health planning and leadership on health services
Provinces provide universal insured health services to all citizens including Aboriginal peoples. This includes: physician and hospital services. The provinces also provide public health and health promotion off reserve.

15. Fulfilling Our Federal Responsibilities
Supplementary
Health
Insurance
Health Care
Services
$1.4B Budget in
( 900M €, 240.8B HUF)
Health
Promotion
& Prevention
Environmental
Health
All Eligible First Nations and Inuit
Supplementary health benefits to all Status Indians and Inuit
- drugs, dental, vision, medical equipment, mental health counseling
First Nations On-Reserve
Public health services
Prevention/health promotion programs
Alcohol/drug addiction and prevention
Medical transportation
Isolated and Remote Communities
Primary care (e.g., nurse practitioners / physicians) including assessment, diagnosis and referral to other health care services
Emergency treatment services
Currency Conversion ( as of June 26, 2003):
1 Canadian Dollar ($) = Euro (€)
= Hungarian Florint (HUF)

16. Health Canada’s First Nations and Inuit Health Branch (FNIHB)
Key Objectives of FNIHB:
To assist First Nations and Inuit communities to improve their health
To ensure the availability of, or access to, quality health services
To facilitate First Nations and Inuit control of health programs and services

17. Federal health services to First Nations and Inuit: a Brief History
The Government of Canada has provided health services to First Nations and Inuit for many years:
Involved in health services delivery since 1904
First of several hospitals built in 1917 – well before modern Medicare
First nurses hired in 1922 – by 1924 all reserves had doctors on part time service
System of nursing stations developed in 1950s
Role evolved in the 1980s to promote more involvement of First Nation and Inuit organizations in the delivery – about 80% of community based services now managed by First Nations and Inuit

18. Health Policy
The 1979 Indian Health Policy is built on three principles:
(1) Community development
Both socio-economic and cultural-spiritual
To remove conditions of poverty and apathy which prevent members of the community from achieving a state of physical, mental and emotional well-being
(2) Traditional relationship of Aboriginal People to
the Federal Government
Federal government acts as advocate of the interests of Aboriginal communities to the larger Canadian society
It promotes the capacity of Aboriginal communities to achieve their aspirations
(3) Canadian Health System

19. Health Service Transfer
1988 Indian Health Service Transfer Policy
Enables First Nations and Inuit communities to design,
health programs, establish services and allocate
funds according to community priorities
Emphasis on increased First Nations and Inuit control
of their health services is a first step in recognizing
that environmental factors, rather than individual and
cultural pathologies, form the basis of health problems
Approximately 82% of community-based health
services are managed by First Nations and Inuit
47% of FN communities have community-based transfer agreements
23% of FN communities have signed Integrated community-based transfer agreements
12% of FN communities are involved in pre-transfer planning
Federal government's relationship with First Nations and Inuit has evolved over the years.
Medical Services Branch created in 1962 to provided direct health services to Indians, growing to a large health delivery service organization: 22 hospitals with 2172 beds, 30 clinics and 30 nursing stations.
In the 1980's, the philosophy shifted to a more collaborative process. Fn and Inuit have become increasingly involved in the management of their health care to ensure that the health system meets and adapts to the needs of individual communities.

20. First Nations and Inuit Health Branch
3 Major Program Directorates
Community Programs
Non-Insured Health Benefits Program
Primary Care and Public Health
Including:
Over 800 community health nurses
82 nursing stations
202 health centres
54 alcohol/drug abuse in-patient treatment centres
10 youth solvent abuse in-patient treatment centres
166 Aboriginal Head Start on-reserve projects

21. FNIHB Program Responsibilities
All Eligible First Nations and Inuit People
On All First Nations Reserves
In Isolated and Remote Communities
- Vision-care
- Dental treatment
- Drugs
Crisis mental health
Provincial health
premiums
Prevention and
promotion programs
Public health
Alcohol/drug
addiction prevention
Medical
transportation
program
Nurse practitioners
and physicians
emergency services
primary care
(assessment,
diagnosis and
referral to other
health care services)
All Eligible First Nations and Inuit
Supplementary health benefits to all Status Indians and Inuit
- drugs, dental, vision, medical equipment, mental health counseling
First Nations On-Reserve
Public health services
Prevention/health promotion programs
Alcohol/drug addiction and prevention
Medical transportation
Isolated and Remote Communities
Primary care (e.g., nurse practitioners / physicians) including assessment, diagnosis and referral to other health care services
Emergency treatment services

22. Forecast
Anticipated Expenditures $1,462.4M Cdn (946.8M €, 251.7B HUF)
Community Health Programs $704.7M Cdn (456.3M €,121.3B HUF)
Non-Insured Health Benefits $684.1M Cdn (442.9M €,117.7B HUF)
Hospitals $23.8M Cdn (15.4M €, 4.1B HUF)
Program Delivery&Administration $49.8M Cdn (32.3M €, 8.56B HUF)
Hospitals 1.6%
Prog Del & Admin
3.4%
NIHB Breakdown Total $684.1M
Drugs $283.7M
Transportation $205.8M
Dental $129.4M
Vision $22.8M
Premiums $26.5M
Mental Health $15.9M
NIHB %
CHP %

23. Public & Environmental Health
On-reserve Public / Environmental Health
COMMUNICABLE DISEASE
Communicable
Disease Control
HIV/AIDs Strategy
Tuberculosis
Elimination Strategy
ENVIRONMENTAL HEALTH
Environmental Health Program
Environmental Contaminants Program
Through the Public and Environmental Health programs, FNIHB aims to address issues that can have a negative impact on health, like drinking water. In the 2003 Budget, the Government of Canada has announced new funding to increase drinking water quality monitoring on-reserve. In addition, plans include funds for remediating federally contaminated sites.
Drinking water quality monitoring
Infectious disease control

24. Health Promotion & Prevention
Upstream investments aimed at improving health outcomes, and reducing health risks
COMMUNITY HEALTH SERVICES
Brighter Futures
Building Healthy Communities
Dental/Oral Health Strategy
FNI Home and Community Care
CHILDREN
Aboriginal Head Start On-Reserve
Canada Prenatal Nutrition Program
FAS /FAE – Fetal Alcohol
Syndrome /Effects Initiative
Rather than simply treating illness, FNIHB delivers many promotion and prevention programs.
Many of these programs operate as a branch of a Canada-wide umbrella program, in an effort, to make program delivery and tools more culturally-sensitive to First Nation and Inuit traditions.
Health promotion and prevention programs are considered upstream investments aimed at positively impacting long-term health outcomes, reducing health risks and mitigating the need for treatment.
Aboriginal children are targeted by many of the programs, with hopes that by ensuring healthy early years, we can give them a better start. For example: the Prenatal Nutrition Program targets mothers before and after the birth of a child to ensure that they are eating well and prepared physically and emotionally for the arrival of the baby.
ADDICTIONS
National Native Alcohol and Drug Abuse Program
Solvent Abuse Program
Tobacco Control Strategy
CHRONIC DISEASE
Aboriginal Diabetes Initiative

25. Supplementary Health Insurance Non-Insured Health Benefits (NIHB)
Providing medically-necessary health related goods and services
to approx 721,000
eligible registered Indians,
and recognized Inuit and
Innu on or off-reserve
$722M in 2003/ (467M €, 124B HUF)
Drugs
Vision Care
Dental
Medical transportation
Mental Health
Premiums in BC & AB
FNIHB provides health benefits to all eligible First Nations and Inuit living both on or off reserve.
The Non-Insured Health Benefits program covers drugs, vision care, dental, medical transportation and mental health. In British Columbia and Alberta the NIHB program also covers provincial premiums.
There are no co-payments nor premiums charged to First Nations and Inuit receiving NIHB benefits.

26. Federal Commitment to Early Childhood Development
…through the Aboriginal Head Start Program …
Six components include:
culture and language
nutrition
health promotion
parental & family involvement
social support
Education
Cooperate with Aboriginal communities and provinces / territories
on the measures required to reduce the number of Aboriginal
newborns affected by Fetal Alcohol Spectrum Disorder.

27. Telemedicine … an example of working collaboratively… Telemedicine:
To address health inequalities and remote populations, many countries are exploring the application of new technologies such as telemedicine
Telemedicine and Canadian First Nations and Inuit:
Over 1/3 of First Nation and Inuit communities are located more than 90 km from physician services
First Nations and Inuit Telemedicine could become a distinct component of Canadian telehealth
Part of larger federal initiatives to assist First Nations in developing Health infostructure capacity
Designed and implemented in full partnership with First Nations communities
Community-based technology and Community driven

28. Working towards Reconciliation…
Aboriginal Healing Foundation
Created in 1998 to encourage and support Aboriginal people as they address the intergenerational legacy of physical and sexual abuse in government and church-run residential schools
$350 Million for community-based projects
Prevention of abuse and process of reconciliation between Aboriginal people and Canadians are vital elements in building healthy communities
Challenge: How to best support FNI in their desire for control and responsibility.
FNIHB support increased control of health services by First Nation and Inuit. Over the last 15 years, FNIHB has been working to increase the capacity of FNI communities to deliver health care services. The wide variety of FNI communities (size/location/leadership) means that we must have a wide variety of vehicles to permit them taking on the level of responsibility they are both comfortable with can be held accountable for.
In closing, increased collaboration with First Nations and Inuit and the provincial and territorial governments offers the best route to improving health care services for First Nations and Inuit. Only through successful partnerships will the Government of Canada be able to fulfill its commitment to “closing the gap in health status between Aboriginal and non-Aboriginal Canadians.
Assembly of First Nations – National Chiefs and Chiefs Committee on Health
Inuit Tapiriit Kanatami – President and Health Committee
CIHR, Aboriginal Centre
Region First Nations and Inuit Groups:
- BC Chiefs Health Committee Treaty Six, Seven and Eight
- Federation of Saskatchewan Indian Assembly of Manitoba Chiefs
- Chiefs of Ontario Assembly of First Nations of Quebec and Labrador
- Atlantic Policy Congress Council for Yukon First Nations
- Dene Nation (NWT) Labrador Inuit Health Commission

29. National and Regional Partnerships
ITK
Inuit
Tapiriit Kanatami
AFN
Assembly
of First Nations
National collaboration through:
Joint Health Renewal Committee
FNIHB Branch Executive Committee
Community Health Program Steering Committees
Challenge: How to best support FNI in their desire for control and responsibility.
FNIHB support increased control of health services by First Nation and Inuit. Over the last 15 years, FNIHB has been working to increase the capacity of FNI communities to deliver health care services. The wide variety of FNI communities (size/location/leadership) means that we must have a wide variety of vehicles to permit them taking on the level of responsibility they are both comfortable with can be held accountable for.
In closing, increased collaboration with First Nations and Inuit and the provincial and territorial governments offers the best route to improving health care services for First Nations and Inuit. Only through successful partnerships will the Government of Canada be able to fulfill its commitment to “closing the gap in health status between Aboriginal and non-Aboriginal Canadians.
Assembly of First Nations – National Chiefs and Chiefs Committee on Health
Inuit Tapiriit Kanatami – President and Health Committee
CIHR, Aboriginal Centre
Region First Nations and Inuit Groups:
- BC Chiefs Health Committee Treaty Six, Seven and Eight
- Federation of Saskatchewan Indian Assembly of Manitoba Chiefs
- Chiefs of Ontario Assembly of First Nations of Quebec and Labrador
- Atlantic Policy Congress Council for Yukon First Nations
- Dene Nation (NWT) Labrador Inuit Health Commission
Regional collaboration through:
Contribution Agreements
Regional Planning

30. National Aboriginal Organizations
CAP
Congress of Aboriginal Peoples
Representing off-reserve Indians and Metis people living in urban, rural and remote areas throughout Canada
MNC
Metis National Council
National representative of the Metis Nation in Canada
NWAC
Native Women’s Association of Canada
A non-profit organization presenting a national voice for Native women

31. National Aboriginal Health Organization
Independent, arms-length organization that is:
Of Aboriginal design and control;
Dedicated to improving the physical, mental, emotional, social and spiritual health of Aboriginal peoples;
Committed to the protection and validation of traditional knowledge; and
Linking the Aboriginal community worldwide to health information and best practices in order to advance Aboriginal healing and wellness practices
Health Canada is funding NAHO to conduct the Regional Longitudinal Health Survey
We provide NAHO $5M annually

32. Canadian Institutes of Health Research
The CIHR Institute for Aboriginal Peoples‘ Health (IAPH) supports research that addresses the special health needs of Canada's Aboriginal people.
IAPH has identified four strategic research priorities for :
Forge health research partnerships and share knowledge
Respect aboriginal values and cultures
Build aboriginal health research capacity
Fund initiatives that address urgent or emerging health issues facing aboriginal peoples
The CIHR Institute for Aboriginal Peoples' Health (IAPH) supports research that addresses the special health needs of Canada's Aboriginal people.
One of the key implementation strategies is the Aboriginal Capacity and Developmental Research Environments Program;
A network of national and regional research centres, affiliated with a recognized research institution.
Launched in 2001, now has 8 centres from Vancouver to Halifax.
Other areas of focus include: diabetes, injuries, child and youth health, mental health, and traditional approaches to healing.
FNIHB has collaborated with IAPH on several initiatives, including the development of an international network indigenous peoples' health researchers, involving the research institutes and governments of Australia, New Zealand and Canada.

33. What We’ve Learned
Evidence shows that First Nations and Inuit ownership of community-based health programs / services leads to better health outcomes
Work done for communities will fail; work done with communities
will succeed
Constructive, collaborative and early engagement of Aboriginal peoples on the design and implementation of programs will yield greater prospects for success.
Much of the improvement in health of First Nations and Inuit people could be influenced by factors outside the health sector, including: Economic Development; Cultural Change; Education; Environment; and Aboriginal People Themselves (i.e. attitude, hope)
Achieving real change in health status will require integrated strategies that address broader socio-economic determinants such as economic development, cultural change, education, social and physical environments and Aboriginal peoples themselves.
Key among other lessons learned is the importance of working collaboratively with Aboriginal peoples to identify and promote their own priorities for health and to build appropriate health systems and strategies to respond to these priorities.

34. Contacts First Nations and Inuit Health Branch:
National Aboriginal Health Organization:
Canadian Institutes of Health Research - Institute of Aboriginal Peoples Health: