COMMENTARY

The First Nations Health Authority: A transformation in healthcare for BC First Nations

Healthcare Management Forum 2015, Vol. 28(6) 255-261 ª 2015 The Canadian College of Health Leaders. All rights reserved. Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0840470415600131 hmf.sagepub.com

Joe Gallagher, B.A.1; Joseph Kiet Mendez, MHA1; and Trevor Kehoe, BAPC1 Abstract More than 10 years of negotiation and a series of political agreements led to the formation of a new First Nations health governance structure in British Columbia and the beginning of new relationships in health between First Nations, federal, and provincial governments. The First Nations Health Authority is the service delivery arm of this structure and the first-of-its-kind for Canada. Equitable and innovative health service and governance partnerships can bring decision-making closer to home and into the hands of First Nations communities and allows using the best of western medicine combined with holistic and traditional practices. Decolonizing old relationships and building new partnerships are leading to greater alignment of culturally safe and effective health services through coordination, integration, and shared decision-making in British Columbia.

Foreword The First Nations Health Authority (FNHA) is a one-of-a-kind health authority in Canada. The FNHA was created by and for First Nations in British Columbia (BC) with a dynamic mandate to elevate the health and wellness outcomes for First Nations peoples in the province. As shown in Figure 1, it has been nearly a decade since the historic work began to outline a path forward towards health transformation for First Nations in BC. Over the years, many committed partners and visionary leaders have come together and agreed that the gaps in health outcomes between First Nations peoples and the rest of the provincial population are no longer acceptable. This consensus eventually led to the transfer of the core functions of Health Canada’s First Nations and Inuit Health Branch (FNIHB) Pacific Region to the FNHA between July and October 2013. The transfer included nearly 200 Health Canada staff as well as direct service responsibility to First Nations communities in areas such as health promotion, health protection, nursing, environmental health, the Non-Insured Health Benefits program, and federal funding arrangements of First Nations health services for communities and support organizations in BC. Partnerships play a significant role in the effectiveness of the new health governance arrangement in BC. Leveraging provincial services for First Nations citizens and an enduring governance relationship with Health Canada allow for principled and effective health service integration with First Nations communities. A clear goal of this new health governance structure is to position BC First Nations to own self-determination in health. To that end, the concept of Reciprocal Accountability guides the navigation of these health system partnerships. This concept also applies to the client level, with First Nations individuals taking responsibility for their wellness decisions and charting their own path to better health outcomes.

The work of the FNHA and its partner organizations, the First Nations Health Council (FNHC) and the First Nations Health Directors Association (FNHDA), is more than providing direct health services. The overarching objective is to return community- and regional-level decision-making to First Nations communities and decolonize relationships between health professionals and government partners in their territories.

Transformative change Health service gaps exist and have been exacerbated for First Nations communities by a federal obligation for healthcare through the Indian Act and due to the boundaries of on-reserve and off-reserve service delivery. However, under the Canada Health Act,2 each province is responsible for health services for all citizens residing within its boundaries. Thus emerges a jurisdictional mix of responsibility and accountability that leaves First Nations communities lost in the middle of distant partners. With 203 recognized First Nations communities in BC delivering varying levels of health services through almost as many agreements with the federal government’s FNIHB, the final result is an inefficient population health focus marked by a lack of communication, coordination, and integration of services. Political views on how to approach the unacceptable difference in health outcomes between First Nations and other British Columbians were varied and numerous. Statistics showed3 a new attitude and methodology was required, and that politics must be put aside to address health inequities. The First Nations Leadership Accord4 between the BC Assembly of 1

First Nations Health Authority, Vancouver, British Columbia, Canada.

Corresponding author: Joseph Mendez, First Nations Health Authority, Vancouver, British Columbia, Canada. E-mail: [email protected]

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Figure 1. British Columbia (BC) First Nations Health Governance timeline—copyrighted by First Nations Health Authority, used with permission1

Figure 2. First Nations Health Governance ecosystem—copyrighted by First Nations Health Authority, used with permission9

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Figure 3. First Nations Health Authority (FNHA) engagement and approvals pathway—copyrighted by First Nations Health Authority, used with permission10

First Nations, First Nations Summit, and Union of BC Indian Chiefs was a way to work together to move towards improving the quality of life for BC First Nations. This unity of purpose and collective voice provided assurance to BC First Nations and their partners. First Nations leaders found that speaking with one voice was the most effective way to work with federal and provincial partners—a theme that would emerge through the entire health transformation process. Between 2005 and 2011, a number of guiding documents and agreements were signed by the Tripartite partners (First Nations leadership and representatives from the federal and provincial governments) that committed each party to working together to close the gaps in the areas of health, education, housing, and economic opportunities. These visionary documents such as the 2005 Transformative Change Accord,5 2006 Transformative Change Accord: First Nations Health Plan,6 and 2007 Tripartite First Nations Health Plan7 led to the establishment of the First Nations Health Governance structure and the eventual transfer of health services

through the Framework Agreement on First Nations Health Governance.8 Fundamental to making progress was the recognition by all partners that transformative change would require a committed collaborative approach and adequate resourcing to do the job.

Credible, transparent, and accountable governance structures The FNHA is one of the four components of a holistic and interdependent First Nations Health Governance Structure as outlined in Figure 2. 1. The FNHA manages, designs, delivers, and funds health and wellness programs, services, and initiatives in partnership with BC First Nations communities. This work is closely tied to partnerships with Health Canada, the BC Ministry of Health, and regional health authorities to integrate health programming for better health outcomes for BC First Nations.

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Figure 4. First Nations Health Authority (FNHA) 7 Directives—copyrighted by First Nations Health Authority, used with permission11

2. The FNHC provides governance, leadership, and oversight for the implementation of health plans and is responsible for maintaining the holistic governance structure established by BC First Nations. Council

members also act as the legal serving members of the FNHA non-profit society. 3. The FNHDA consists of health directors and managers working in First Nations communities. The FNHDA

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supports education, knowledge transfer, professional development, and best practices for health directors and managers. The FNHDA also acts as a technical advisory body to the FNHC and the FNHA on research, policy, program planning and design, and the implementation of the health plans. 4. The Tripartite Committee on First Nations Health (TCFNH) coordinates and aligns programming and planning for BC First Nations health and wellness across the entire provincial system. Members of the TCFNH include federal and provincial partners through Health Canada and the BC Ministry of Health, members of the FNHC, FNHA, FNHDA, regional and provincial health authorities, the provincial health officer, and deputy provincial health officer.

Reciprocal accountability The FNHA is an innovative and evolving organization, grounded in First Nations philosophy and operating within a multi-faceted environment. A collective BC First Nations voice led to the creation of the FNHA, and a first-of-its-kind governing structure that effectively separates business from politics, while respecting both. Many First Nations leaders have demonstrated vision and insight in transforming the former relationship between First Nations in BC and the federal and provincial governments. The new relationship is a true partnership where all are committed to working towards a shared vision of ‘‘Healthy, SelfDetermining, and Vibrant BC First Nations Children, Families and Communities’’. Many First Nations social systems are founded on the concept of reciprocal accountability as outlined in Figure 3. Each member of the community is accountable for their decisions, actions, and contributions to the community’s wellness as a whole. At its core, reciprocal accountability means being responsible and sharing successes and challenges. Reciprocal accountability pairs expectations with the means to deliver on them. The quality of care provided through a health system depends upon what is collectively contributed both by owners and by users of the health authority resources. The concept of reciprocal accountability is central to the First Nations Health Governance Structure and all FNHA partnerships. Reciprocal accountability makes clear where the responsibility rests for each individual’s personal wellness journey.

FNHA services The FNHA occupies a completely unique place in the health system in BC, holding strategic policy functions, service delivery functions, and population health functions at all levels. The FNHA offers a full spectrum of health services and support depending on the needs of the First Nations community. For some of the 203 First Nations communities in BC, health services provided by the FNHA are comprehensive. For

Figure 5. First Nations Perspective on Wellness—copyrighted by First Nations Health Authority, used with permission13

other First Nations communities, the FNHA acts primarily as a funding partner because these communities deliver their own health services (due to the federal health transfer process12 which began in the 1980s). The FNHA community-based services are largely focused on health promotion, disease prevention, and primary care services. Health services include children, youth, and maternal health; mental health and substance use programming; health and wellness planning; health infrastructure and human resources; environmental health and research; First Nations health benefits; and eHealth technology. The FNHA does not replace or duplicate health services provided by the Ministry of Health and regional health authorities. Regional health authorities in BC oversee and coordinate the delivery of core primary care and specialist health services for First Nations citizens in urban areas across the province. First Nations communities, the FNHA, FNHC, and FNHDA have been strengthening working relationships with staff and senior leadership within each health authority. Each First Nations regional caucus has entered into a partnership accord with its respective regional health authority supported by the FNHC with the FNHA as a signatory. Regional partnership accords act as a shared commitment to work collaboratively to strengthen working relationships and achieve greater alignment of regional healthcare priorities with community and regional health plans developed by First Nations. Each partnership accord reflects specific regional mandates, initiatives, milestones, and outcomes and follows the 7 directives as shown in Figure 4. Provisions include establishing joint

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Figure 6. First Nations Health Authority (FNHA) operating principles—copyrighted by First Nations Health Authority, used with permission14

health and wellness committees, increasing cultural competency among health authority staff, advancing First Nations human resources strategies, improving coordination and integration of primary care, and access to services in rural and remote communities.

Early success Wellness is a philosophy of the FNHA. It is holistic and includes living well through a balanced lifestyle and a harmonious relationship with one’s environment. The First

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Nations Perspective on Wellness image aims to create a shared understanding of FNHA’s holistic vision of wellness, as shown in Figure 5. Wellness for First Nations encompasses the mental, physical, emotional, environmental, social, economic, cultural, and spiritual aspects of an individual, family, and community. To support individual wellness as a way to own personal health outcomes, the FNHA supports hundreds of wellness events and initiatives across the province every year. One of the most popular was the ‘‘Beefy Chiefs and Champions’’ FNHC annual health leadership challenge supported by the FNHA. Early successes of the Tripartite health transfer in BC include additional staff for the five regions, clinical telehealth deployment to remote communities, a customized communications and community engagement approach, and numerous partnerships with professional associations such as the College of Physicians and Surgeons of BC, the College of Dental Surgeons of BC, the College of Pharmacists, and Doctors of BC and partnerships with universities across the province. The FNHA has also established a senior level table with the BC Ministry of Health to improve primary care and mental health. Thanks to this new Joint Project Board table, innovative integrated Community of Care models are being created in partnership with regional health authorities and First Nations communities.

Looking ahead The FNHA keeps at the core of its operations, see Figure 6, the 7 directives and shared values given by First Nations in BC. This transformational work requires a profound commitment to uphold the shared values of respect, discipline, relationships, culture, excellence, and fairness. In a robust planning, evaluation, and reporting framework, the FNHA takes its commitment to reciprocal accountably and responsibility to BC First Nations to heart. The FNHA is implementing a wellness-based approach to health services, human resource management and employee engagement, and recruitment and retention, while pursuing operational excellence and accreditation. Cultural humility is a hallmark of the FNHA. The organization seeks to offer and promote culturally safe and effective healthcare for First Nations people, as a community-focused health and wellness organization. The FNHA is committed to a health and wellness approach that is founded in First Nations knowledge and teaching. Listening, learning, and acting on what BC First Nations expect from their health authority and defining a collective accountability to improve health opportunities and outcomes relates to working with and not for communities in the design and delivery of their health services. Looking ahead, the FNHA and its partners will continue on the transformative journey towards a future of Healthy, Self-

Determining and Vibrant BC First Nations Children, Families and Communities. References 1. First Nations Health Authority. BC First Nations Health Governance Timeline. Available at: http://www.fnha.ca/about/transitionand-transformation/timeline. Accessed July 2015. 2. Government of Canada. Provincial/territorial role in health. Available at: http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/ ptrole/index-eng.php. Accessed July 2015. 3. British Columbia. Provincial Health Officer. (2009) Pathways to Health and Healing – 2nd Report on the Health and Well-being of Aboriginal People in British Columbia. Provincial Health Officer’s Annual Report 2007. Victoria, BC: Ministry of Healthy Living and Sport. 4. First Nations Summit. Leadership Accord. Available at: http://www.fns.bc.ca/pdf/afnfnsubcicLeader.pdf. Accessed July 2015. 5. First Nations Health Authority. Transformative Change Accord. Available at: http://www.fnha.ca/Documents/transformative_ change_accord.pdf. Accessed July 2015. 6. First Nations Health Authority. Transformative Change Accord: First Nations Health Plan. Available at: http://www.fnha.ca/Documents/TCA_FNHP.pdf. Accessed July 2015. 7. First Nations Health Authority. Tripartite First Nations Health Plan. Available at: http://www.fnha.ca/Documents/TripartiteFNHealthPlan.pdf. Accessed July 2015. 8. First Nations Health Council. British Columbia Tripartite Framework Agreement on First Nation Health Governance. Available at: http://www.fnhc.ca/pdf/framework-accord-cadreeng1.pdf. Accessed July 2015. 9. First Nations Health Authority. First Nations Health Governance Ecosystem. Accessed July 2015. 10. First Nations Health Authority. FNHA Engagement and Approvals Pathway. Available at: http://www.fnha.ca/about/governance-and-accountability/engagement-process. Accessed July 2015. 11. First Nations Health Authority. FNHA Seven Directives. Available at: http://www.fnha.ca/about/fnha-overview/directives. Accessed July 2015. 12. First Nations and Inuit Health. Ten Years of Health Transfer First Nation and Inuit Control. Available at: http://www.hc-sc.gc.ca/ fniah-spnia/pubs/finance/_agree-accord/10_years_ans_trans/ index-eng.php. Accessed July 2015. 13. First Nations Health Authority. First Nations Perspective on Wellness. Available at: http://www.fnha.ca/wellness/wellnessand-the-first-nations-health-authority/first-nations-perspectiveon-wellness. Accessed July 2015. 14. First Nations Health Authority. FNHA Operating Principles. Accessed July 2015.

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The First Nations Health Authority: A transformation in healthcare for BC First Nations.

More than 10 years of negotiation and a series of political agreements led to the formation of a new First Nations health governance structure in Brit...
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