Indigenous Health

KEY POINTS

• Addressing health inequities experienced by Indigenous peoples requires meaningful relationship-building, investment of resources and empowering self-determination through innovation.

• Alberta Health Services recognizes the importance of acting upon the United Nations Declaration on the Rights of Indigenous Peoples and the Truth and Reconciliation Commission’s Calls to Action, and the Indigenous health arm of the Population, Public & Indigenous Health Strategic Clinical Network is a key vehicle to deliver the required innovation.

• Changes to the Alberta health system must occur in partnership with Indigenous peoples.

• Trusting relationships are developed over time with combinations of meaningful engagement and showing accountability by undertaking agreed upon actions.

Health inequities for Indigenous peoples arise from the multigenerational effects of colonization and need to be contextualized within the historical, political, social and economic conditions that have influenced Indigenous health.^1–3 Calls for action to address Indigenous inequities have been enshrined in the final report from the Truth and Reconciliation Commission of Canada, the United Nations Declaration on the Rights of Indigenous Peoples and the report from the Royal Commission on Aboriginal Peoples.^4–6 Alberta Health Services (AHS) has fully committed to partnering with Indigenous peoples to address the their unique health needs as part of the reconciliation approach.

A goal of the Indigenous health arm of the Population, Public & Indigenous Health Strategic Clinical Network (PPIH SCN; www.ahs.ca/ppihscn), launched in 2016, is to support AHS’ commitment to closing the gap in health outcomes for First Nations, Métis and Inuit in Alberta. One of the missions of the network is to improve the health and wellness of Indigenous peoples by engaging them as equal partners in their own health, wellness and care at the individual, family and community level; exploring, identifying and embedding equitable, holistic and culturally safe health practices; and acknowledging and addressing health inequities rooted in the determinants of health.⁷

To deliver on this mission, an Indigenous Health Core Committee was established to guide the work of the Indigenous health arm of the PPIH SCN and to foster relationships and interconnections among stakeholders. First Nation, Métis, Inuit peoples and organizations responded to a provincial expression of interest to establish a 55-member network who created the mission, guiding principles and strategic directions for this arm of the PPIH SCN. The committee includes Indigenous health allies representing Indigenous communities, provincial nonprofit organizations, universities, provincial and federal government departments, AHS Zones, provincial programs of Population, Public and Indigenous Health, and is grounded by Indigenous Knowledge Keepers. Indigenous Services Canada is a member and provides a federal perspective to help navigate existing jurisdictional complexities.

Indigenous voices are critical to decision-making, which is reflected in the PPIH SCN’s governance structure and approach. The work of the Indigenous health arm of the PPIH SCN is grounded in collaboration with individual Indigenous communities in a strengths-based approach. Initiatives are selected and led by Indigenous peoples in support of meaningful, sustainable change, while also entrenching guiding principles into AHS’ organizational memory.⁷ Prioritizing opportunities, empowering discussions and ensuring that solutions are inclusive of Indigenous people’s knowledge ultimately supports Indigenous sovereignty through self-efficacy, self-determination, autonomy and wholism.^8,9

The PPIH SCN is positioned within the provincial Population, Public and Indigenous Health portfolio of AHS to leverage the wisdom and resources of the provincial health system’s existing organizational structure. One department is the Indigenous Health Program whose partnership enables systematic scaling and spreading of proven innovations. Positioned in this manner and within the broader SCN family, the Indigenous health arm of the PPIH SCN creates knowledge and capacity to develop and implement transformative initiatives to reduce inequities in Indigenous health. Linkages with the Wisdom Council, a 19-member council made up of public members from across treaty areas and AHS Zones, ensures alignment and provides guidance on the network’s activities.

The Indigenous health arm of the PPIH SCN used experiential approaches (e.g., sociometry, graphic recordings and talking circles) to establish the necessary platform for raw, honest and heartfelt sharing among members of the Core Committee. Respecting the diversity among Indigenous groups in Alberta was a key directive from these discussions because the historical and contemporary experiences of First Nation, Métis and Inuit people varies across Alberta. A critical lesson for a large health system to learn is the potential harm of taking a pan-Indigenous approach to health without respecting these differences.

The PPIH SCN’s Indigenous Health Transformational Roadmap⁷ envisions a path of partnership to take collective action in 3 strategic directions (see figure): Truth and Reconciliation Calls to Action, Transform Health Services & Systems, and Address Indigenous Determinants of Health. Guiding principles include recognizing the need to build sustainable actions to improve health while simultaneously embracing traditional knowledge and practices, and realizing Indigenous peoples’ health care rights and knowing the distinct health care needs of all Indigenous peoples in the province.

The Transformational Roadmap (https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-ppih-ih-roadmap.pdf) has guided the Indigenous health arm of the PPIH SCN in implementing a diversity of projects to meet the identified strategic directions. The Prevention of Cancer among Indigenous Peoples and Vulnerable Populations grant aims to engage in projects for health innovation and cancer prevention that facilitate positive outcomes toward reducing the incidence of cancer and related modifiable risk factors. The multiprong approach includes projects to build Indigenous community-level researcher capabilities through the Patient and Community Engagement Research internship program, increase rates of cancer screening and practices at primary care clinics with the Alberta Screening and Prevention program and facilitate sustainable Indigenous community-led projects via the Health Innovation and Cancer Prevention grant program. Success of the Patient and Community Engagement Research internship program to date includes 12 Indigenous graduates who produced 4 community-based research projects.

Strategic directions and priorities identified in the Indigenous Health Transformational Roadmap.

Image courtesy of Alberta Health Services

Additional initiatives include co-leading efforts with the AHS South Zone operations team to innovate an Indigenous Patient Navigation Model by learning from and adapting models, policies and partnerships from other jurisdictions, as a means of advancing transformation in the Alberta health care system. The project utilizes a co-design methodology to harness collective wisdom of Indigenous stakeholders and communities to ensure seamless integration of health services that improve patient experiences and health outcomes within Alberta. In addition, the PPIH SCN supports evidence-based initiatives to improve culturally safe service delivery across the province through scaling and spreading proven innovations. For example, the Extended Community Health Outcomes model implements a hub-and-spoke telehealth model for the assessment and treatment of infection with hepatitis C virus. The network is working with partners to spread the initiative to more Indigenous communities in Alberta and scale the model to include prevention, screening and treatment of other sexually transmitted and blood-borne infections.

The development of the Indigenous health arm of the PPIH SCN has had several challenges. One major challenge is accessing and sustaining the attention of colleagues in health care delivery to learn and understand the historical foundations that underpin the current state of Indigenous people’s health. Truth and Reconciliation require a substantial investment in developing new relationships based on deep listening, compassionate understanding and transformative action. Action emerges through humility and the building of trusting relationships. This requires a commitment to take the time needed and to follow a pace that is not under the control of the system, while simultaneously under pressure to act.

Future directions include the development of performance indicators inclusive of both Indigenous and Western ways of knowing to measure and track the ongoing progress of the network. The Indigenous Health Core Committee is currently engaged in an extensive consensus approach to ensure the success of the network is defined by both world views (e.g., increased cancer screening rates among Indigenous peoples and increased reporting that cultural or traditional activities contribute to their overall health). The PPIH SCN envisions performance indicators that are mapped to the reach, effectiveness, adoption, implementation and maintenance¹⁰ of projects and the overall impact of the network. The network is also committed to reporting on changes in health outcomes (e.g., Indigenous life expectancy) and health care utilization (e.g., rates of visits to the emergency department) to monitor ongoing progress in closing unjust and avoidable health inequities. Although the Indigenous health arm of the PPIH SCN is in its early days of trail blazing, it provides the foundation for transformative innovations in Indigenous health in Alberta.