Implementing the Vision: - First Nations Health Council

Implementing the Vision:Governance ofFirst Nations Health Servicesin British Columbiaa w o r k i n g pa p e r of theTripartite Governance Committee

iiWhen implementedthe Tripartite FirstNations Health Planputs control of FirstNations healthcarein the hands of FirstNations people.

Our goal is to enable First Nations to take the lead in designingand delivering healthcare for BC First Nations. This ensuresthat culturally relevant and more effective health services aredelivered at the community level.The HistoryThe Tripartite First Nations Health Plan signed by the FirstNations Leadership Council (FNLC), the Government ofCanada and the Government of British Columbia (BC)on June 11, 2007 committed the parties to put in placea new structure of governance that “leads to improvedaccountability and control of First Nations health servicesby First Nations.”The PlanThe commitments to put in place a new structure ofgovernance for First Nations health and improve andclarify the relationships and reciprocal accountability of theparties are part of an overall 10-year health plan that setsin motion the changes necessary to improve the healthof First Nations in British Columbia and to close the gapsin health status between First Nations people and otherBritish Columbians. The other three elements of the B.C.Tripartite Health Plan are:• Health Promotion/Injury and Disease Prevention: Thisincludes specific program improvements and newinitiatives in Act Now, mental health, maternal andchild health, injury prevention and addictions.• Health Services: This part of the Plan includes a newhealth centre in Lytton, expanded chronic diseaseservices, increased training of Aboriginal professionalsand improved access to primary care.• Performance Tracking: This element includes reportson Aboriginal health every five years by the ProvincialHealth Officer, improved surveys and reporting,and the measurement of progress against identifiedperformance indicators.1

2Key principles underlying the Plan• Respect for cultural knowledge and traditional healthpractices;• Respect for diversity;• A commitment to overcome jurisdictional issuesthrough “effective working relations”;• A commitment to deal with the determinants of health;• No duplication of programs and services, and nocreation of a parallel health system;• A commitment to reciprocal accountability; and• Open and timely information-sharing.The Plan CommitmentsThe Plan set out an agreed vision for governance reformthat would result in health service delivery that reflects theneeds of First Nations. It identified four components:• a First Nations Health Governing Body (which is now beingcalled a First Nations healthy authority) that wouldenact policies, identify results, allocate resources,establish service standards and implement ongoingreciprocal accountability measures;• a First Nations Health Council that would serve as anadvocacy voice for First Nations, participate in federaland provincial policy and planning processes, andprovide leadership to implement the Plan;• a Tripartite First Nations Health Advisory Committee(now called the Provincial Advisory Committee on FirstNations Health) to monitor health outcomes and theAboriginal Health Plans of Regional Health Authoritiesand to recommend actions to the Parties; and,• First Nations Health Directors Association composedof First Nations Health Directors and other healthprofessionals to focus on capacity building, training,knowledge transfer and professional input andsupport for First Nations health programs within B.C.Every party is committed to honouring the principles underlyingthe Plan – and that is what will ensure its success.

First Nations people and healthcare workers designing anddelivering services to BC First Nations know what ought to bedone to ensure needs are met. This is your opportunity to tell uswhat works and what doesn’t.The Processfor establishing a new governance structureThe details of a new structure of governance are to beworked out by “a tripartite committee” within three years ofthe signing. The parties have created that committee, withFirst Nations being represented by the First Nations InterimHealth Governance Committee, the federal governmentby Health Canada headquarters and regional designates,and the provincial government by representatives of theMinistry of Healthy Living and Sport.The Tripartite Governance Committee has begundiscussions about how to implement the vision forgovernance that was set out in the Tripartite Plan. Thispaper captures some of the emerging ideas concerningthe roles and responsibilities of the various components ofthe new governance structure and the anticipated effecton the current organizations and ways of functioning.This paper is seeking your views and advice on thesedeveloping ideas.Read this publication and share your views andadvice on its content.Promoting good governanceThe vision that is set out in the Plan speaks to closing thegaps in health and to ensuring that First Nations are fullyinvolved in decision-making. The plan identified a numberof specific aspects that the new governance structurewould need to include or achieve. These aspects include:• a comprehensive health plan for each First Nation;• services that meet the needs of First Nationscommunities and individuals no matter where theylive;• greater control by First Nations;• effective linkage between First Nations deliveredservices and those delivered by provincial healthauthorities; and• Health Canada’s evolution from a designerand deliverer of health services to a funder andgovernance partner.3

4A sound,accountablegovernancestructure is thecornerstone ofthe new Plan.

Emerging PictureThe path that brought us to this pointThe Tripartite Governance Committee has started its workand has spent considerable time getting information on thecurrent structure and organization of First Nations healthprograms and services in British Columbia, identifying therole and responsibilities of the current organizations, andconsidering how the new First Nations Health structurescould work together. As part of this discussion, theprovince acknowledges its role as a governance partnerand funder.The four components of governance (the First NationsHealth Council, the Provincial Advisory Committee on FirstNations Health, a First Nations Health Governing Body--proposed to be called a First Nations health authority--and the First Nations Health Directors Association) allhave a critical role to play and must work closely with FirstNations community health organizations to substantiallyimprove the health services and health status of FirstNations.Consulting with stakeholdersThe Tripartite Governance Committee has sought inputfrom many individuals and organizations. Based on thisinput and the discussions that we have had, the TripartiteGovernance Committee has identified a number of criteriathat the new system of governance needs to achieve.• It must be fully accountable to First Nations.• It should reduce bureaucracy and maximize services.• Its policies and programs should be based on thecomprehensive health plans of B.C. First Nations.• It should improve efficiency in both administration andhealth service delivery;• It should be founded on a First Nations definitionof health that is holistic and includes the physical,mental, emotional, spiritual and social aspects.• It should support a comprehensive set of publichealth, health promotion and disease prevention andprimary health services.• It would operate in partnership (with clearly definedroles and responsibilities, authority and jurisdiction)with the health programs and authorities of theprovincial and federal governments.• It should include special provisions for effective servicedelivery where there are multiple jurisdictions andmultiple service organizations, such as in the case ofurban and off-reserve First Nations people.• It should develop clear and systematic workingrelationships between First Nations healthorganizations and provincial health organizationsand support clarification of roles and responsibilities,better co-ordination, shared goals and planning, andimproved results for the First Nations communities ofBC.• It should work with other components of the BChealth system through direct and indirect measures toimprove health services across the continuum.5

6How do we get there?Work has begun on various components that will helpdefine and develop the new governance structure that willassume responsibility for the design and delivery of healthprograms and services for BC First Nations:First Nations Health Council: Created in February 2007,the First Nations Health Council (FNHC) is made up ofrepresentatives appointed by the First Nations Summit,the Union of British Columbia Indian Chiefs and the BCAssembly of First Nations and meets on a quarterly basis.In April 2009 the Council developed a First Nations HealthSociety to act as its business entity. This business entityis an interim measure that has been put in place until thenew First Nations health governance structure is finalized.Provincial Advisory Committee on First Nations Health:Established in September 2007, this committee is cochairedby a representative of the First Nations HealthCouncil, the Deputy Ministers of Healthy Living and Sportand Health Services (Province of British Columbia) andthe Regional Director General, Health Canada to improveaccountability to First Nations. The committee hasestablished its terms of reference and meets regularly toreview and monitor the health plans of B.C.’s RegionalHealth Authorities.First Nations Health Directors Association: In September2008 a working group of Health Directors organized aforum for Health Directors, who discussed the roles andresponsibilities of the proposed Association as well as itsmembership and governing structure. A survey of HealthDirectors was conducted and focus group sessions havebeen held to gather information that will help establishthe Association. In addition, research is being conductedto develop recommendations that will be distributed forconsideration in the fall of 2009 with the goal of reachingan agreement on the structure and role of the Associationby the end of 2009.First Nations Health Governing Body (First Nations healthauthority): A new First Nations health authority has beenthe subject of considerable discussion at the meetingsof the Tripartite Governance Committee and is seen asthe most challenging, and perhaps most critical, of theelements of the new governance structure.The ChallengeCreating a new First Nations governance structure for FirstNations Health Services that will assume responsibility foragreed upon health and service functions that are currentlycarried out by federal and provincial authorities.The BC Tripartite Governance Committee suggests itwould be helpful to think of this new body as a FirstNations health authority that would provide the technical,professional and policy leadership in health for FirstNations, to achieve better working relations with federaland provincial partners.It is proposed that there be a transitional phase duringwhich the First Nations health authority would assumeresponsibility of the current complement of management,staff and resources of Health Canada’s First Nationsand Inuit Health program in BC. This new body will notsolely be seen as a replacement to the current federaldelivery structures, but rather it will be designed to yieldan improved capacity to advance the health status of FirstNations people in BC.It would not impede, infringe on, ordiminish First Nations inherent rights and title, Aboriginaland Treaty rights, and future treaty negotiations.To meet that goal, it is anticipated that the neworganization would maintain what works well while striving

Share yourviews andadvice, tell uswhat works andwhat doesn’t.7

Each party willmaintain an ongoingcollaborativerelationshipbased on respect,reconciliation, andrecognition of eachother’s roles asgovernance partners.8

to increase efficiencies and accountability. Its efforts wouldbe focused on systematically developing the capacity forFirst Nations and enabling First Nations to design anddeliver first-class health services.Envisioned OutcomeThe anticipated outcome of this process is the creation ofa First Nations health authority which would deliver and/or fund a broad array of programs designed to meet thehealth needs of BC First Nations. This would likely includethose programs currently funded or delivered by FirstNations and Inuit Health (Health Canada) and other agreedupon federal and provincial health services.Enhanced, and considerably expanded, First Nationsrole in design and delivery of health services for BCFirst NationsThe parties responsible for negotiating the structure andresponsibilities of the new First Nations healthy authorityrecognize that the very existence of a First Nations healthyauthority, whereby First Nations will design and deliverhealth services for First Nations, will support improvedservices and contribute to better health outcomes byincreasing self-determination and self-actualization,proven determinants of good health.A new jurisdictional model that capitalizes on FirstNations knowledge for the benefit of allA First Nations healthy authority would operate inpartnership (with clearly defined roles and responsibilities,authority and jurisdiction) with the health programs andauthorities of the provincial and federal governments.The jurisdictional model adopted will support effectiveand efficient service delivery to First Nations peopleregardless of where they live in British Columbia. It wouldalso recognize that there are circumstances where it willbe advantageous for a First Nations healthy authority orFirst Nations communities or First Nations organizations toorganize and deliver health services to non-First Nationsclients.Changes to existing management structuresThe creation of this new model of governance will beaccompanied by changes within Health Canada’s FirstNations and Inuit Health program management structure.These changes would facilitate improved coordination andcooperation among the parties and will also identify newmechanisms that allow BC First Nations to participate inthe development of future health policies, programs andinitiatives.Extensive cooperation between the new First Nationshealth authority and the First Nations Health DirectorsAssociationThe new First Nations health authority would have aclear relationship with the First Nations Health DirectorsAssociation which will represent health professionals,managers, technicians, and other staff have a major roleto play in achieving better health outcomes for BC FirstNations.The new governance system would define clear roles forhealth professionals and managers related to implementingquality assurance mechanisms, program design, andcommunity program support. The development of aneffective relationship with universities and colleges will alsoplay a critical role in providing a proactive environmentfor the training, recruitment, and retention of healthprofessionals and related occupations, and in supporting9

10ongoing training and professional development programsthat will build capacity among First Nations staff.It is also recognized, by all parties, that competitive salariesand healthy working conditions, combined with accessto a broad array of continuing education and trainingopportunities, are essential underpinnings of a vibrant andstable workforce.Developing a Health InformationGovernance FrameworkThe development of a health information governanceframework will be an essential part of the new healthgovernance model and will be supported by the newFirst Nations healthy authority. All parties recognizethat consistent and ongoing First Nations involvementin the control and management of data collection andinformation-sharing represents an opportunity to alignhealth service actions with emerging circumstances at thelocal and regional levels.Appropriate development and implementation of electronicpatient records, consistent or unified with provincialsystems, and attainment of broadband Internet availabilitywill support the development of need-based, clientfocused systems. Reorientation of current programs,based on information and data flowing from thecommunity and service providers, is an important goalof the new health system.Patterned after the Epi-centre model, which has beenimplemented under Tribal control in the United States,this or a similar approach will be carefully examined asa potential means to support the goal of reorientation tocreate a health service that better supports communityservice providers and better serves First Nations.The Tripartite First Nations Health Plan contains acommitment on the part of all the partners to build a newrelationship among themselves, based on mutual respect,recognition and reciprocal accountability.The concept of reciprocal accountability contains thefollowing dimensions of shared accountability:• accountability collectively amongst the partners whenthey act in common,• accountability to each other to carry out eachpartner’s respective commitments and obligations,• accountability of each partner to their own governingbody, and• collective and individual accountability for respectingthe principles of the Tripartite Health Plan.How can we encourage reciprocal accountability?The Tripartite Governance Committee recognizes thateffective monitoring and evaluation of the progress made isessential to reciprocal accountability. The committee will beseeking agreement among the partners on the structureand process for ongoing collaboration, and on measuresthat will make this reciprocal accountability a key elementin keeping the Tripartite Agreement a vibrant and positivecontribution to First Nations Health.

Editing the PictureAs with many of the pictures we take with a digital camera, there is a capacity and sometimes a need to edit thepicture to better capture the vision of what we want. Dialogue with First Nations leadership and health technicians hasbeen ongoing through Regional Governance Caucuses, and the work of the First Nations Interim Health GovernanceCommittee. This picture of an emerging First Nations healthy authority as a key element of the new First Nations HealthGovernance structure in BC is unfolding as we move forward.If you have comments, ideas or concerns with this picture we want to hear from you. Please provide feedback,comments or advice to:Derek ThompsonHealth Governance CoordinatorFirst Nations Health Council1205 – 100 Park Royal SouthWest Vancouver, BCV7T 1A2Phone: 604.913.2080Facsimile: 604. 913.2081Toll Free: 1.866.913.003311Email: dthompson@fnhc.ca

12ANNEX ABC Tripartite Governance CommitteeRichard Jock - ChairGrand Chief Ed John - First Nations Health CouncilGrand Chief Doug Kelly - First Nations Health CouncilChief Shane Gottfriedson - First Nations Health CouncilIan Potter – Health CanadaYousuf Ali – Health CanadaBernard Hanssens – Health CanadaAndy Hazlewood - BC Ministry of Healthy Living and SportDeborah Schwartz - BC Ministry of Healthy Living and SportFirst Nations Interim Governance CommitteeGrand Chief Ed John - First Nations Summit (Co-Chairs)Chief Shane Gottfriedson - Vancouver Interior Representative, Union ofBC Indian Chiefs (Co-Chairs)Grand Chief Doug Kelly - BC Assembly of First Nations (Co-Chairs)Chief Willard Wilson - North RepresentativeChief Margery McRae - North RepresentativeJusta Monk - North RepresentativeWarner Adam - North RepresentativeFeddie Louie - North RepresentativeAnne Marie Sam - North RepresentativeDoris Ronnenberg - North RepresentativeChief Joseph Dennis - Interior RepresentativeGwen Phillips - Interior RepresentativeChief Ko’waintco Michel - Interior RepresentativeChief Darrel Bob - Interior RepresentativeCouncillor June Quipp - Fraser RepresentativeChief Willie Charlie - Fraser RepresentativeCharles Nelson - Vancouver Coastal RepresentativeCliff Atleo - Vancouver Island RepresentativeChief Russ Chipps - Vancouver Island RepresentativeChief Bob Chamberlain - Vancouver Island Representative

The Goal: A FirstNations healthauthority whichwould deliverprograms designedto meet the healthneeds of BC FirstNations.13