Have investments in on-reserve health services and initiatives promoting community control improved First Nations’ health in Manitoba?

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Abstract

The objective of this study was to document the relationship between First Nation’s community characteristics and the rates of hospitalization for Ambulatory Care Sensitive Conditions (ACSC) in the province of Manitoba, Canada. A population-based time trend analysis of selected ACSC was conducted using the de-identified administrative data housed at the Manitoba Centre for Health Policy, including vital statistics and health information. The study population included all Manitoba residents eligible under the universal Manitoba Health Services Insurance Plan and living on First Nation reserves between 1984/85 and 2004/05. Twenty-nine ACSC defined using 3, 4 and 5 digit ICD-9-CM and ICD-10-CM codes permitted cross-sectional and longitudinal comparison of hospitalization rates. The analysis used Generalized Estimated Equation (GEE) modeling.

Two variables were significant in our model: level of access to primary health care on-reserve; and level of local autonomy. Communities with local access to a broader complement of primary health care services showed a lower rate of hospitalization for ACSC. We also examined whether there was a significant trend in the rates of hospitalization for ACSC over time following the signature of an agreement increasing local autonomy over resource allocation. We found the rates of hospitalization for ACSC decreased with each year following the signature of such an agreement.

This article demonstrates that communities with better local access to primary health care consistently show lower rates of ACSC. Secondly, the longer community health services have been under community control, the lower its ACSC rate.

Introduction

Studies have repeatedly reported that the health of Indigenous peoples world-wide is poor, reflecting colonial and post-colonial policies that undermined Indigenous peoples’ cultures, languages and social structures, and resulted in widespread economic marginalization (Anderson et al., 2006, Stephens et al., 2006). In recent decades, Indigenous peoples in many countries have sought to secure more control over community-based health services, in the hope of improving access and responsiveness (United Nations, 2002). This is seen by Indigenous peoples as an expression of their Treaty right (as in New Zealand) and/or Indigenous rights to self-determination (Laing & Pomare, 1994), rights that survived colonisation (especially in Canada and New Zealand, see Havemann, 1999 for a detailed discussion). Governments have responded by developing contractual relationships with Indigenous health organizations that provide a spectrum of primary health care services, ranging from health promotion and prevention, to primary intervention and rehabilitative services (Lavoie, Boulton, & Dwyer, in press). This shift echoes the Alma-Ata Declaration and the Ottawa Charter’s commitment to popular engagement in service planning and delivery (World Health Organisation & UNICEF, 1978, World Health Organisation, 1986, World Health Organisation, 1997).

In Australia, the number of Indigenous primary health care providers has grown to approximately 150 since they first emerged in 1971 (Dwyer, O’Donnell, Lavoie, Marlina, & Sullivan, 2009). In New Zealand, the sector grew from 23 providers in 1993–240 in 2007 (New Zealand Ministry of Health, 2007). In Canada, Health Canada reports that as of March 2008, 83 percent of eligible First Nation communities are involved in managing their own community-based health services (Health Canada (FNIHB), 2008). Although community members have reported improvements in outcomes (Lavoie et al., 2005), the magnitude of these improvements is not known. Likewise, despite international commitments to the ideal of community participation in the planning and delivery of primary health care services, empirical studies demonstrating the linkage between community engagement and outcomes remain inexistent. Perhaps as a result, “if some key principle of Alma-Ata has been lost more than any other, it is that of community participation” (Lawn et al., 2008, p. 924).

The objective of this study was to investigate the relationship between models of community control, on-reserve access to primary health care services and health outcomes among First Nations living in the province of Manitoba, Canada. Manitoba was selected for this study because along with Saskatchewan, Manitoba is home to highest proportion of First Nation peoples in Canada, at nearly ten percent of the provincial population (Statistics Canada, 2008). Second, Manitoba is unique in Canada and among other countries in that works in partnership with the Assembly of Manitoba Chiefs who represents First Nations the Manitoba Centre for Health Policy of the University of Manitoba which houses the Population Health Research Data Repository (herein referred to as the Repository). The Repository consists of provincial administrative databases which are longitudinal, de-identified yet linkable at the person level. This resource facilitates health research in areas that are of relevance to First Nations. Finally, this study was identified as a priority research area by the Assembly of Manitoba Chiefs.

In this study, we conceptualize that health disparities or inequalities exist whenever the health of First Nations lags behind that of other Canadians (Whitehead, 1992). Determinants go beyond access to care, and include other factors such as a history of oppression, genetic make-up, lifestyle choices, socio-economic conditions, environment, education, housing, etc. (Adelson, 2005, Marmot and Wilkinson, 1999, Reading et al., 2007). For the purpose of this study, we are concerned with health inequalities that can be addressed through primary health care interventions. Although the exact role primary health care can play in addressing health inequalities is limited (Marmot & Wilkinson, 1999), reviews by Starfield, Shi, and Macinko (2005) and Macinko, Starfield, and Shi (2003) suggest that better access to primary care and primary prevention is associated with improved access to immunization; smoking cessation; better prenatal outcomes; decreased childhood morbidity; earlier detection of melanoma and breast, colon and cervical cancers; improved outcomes for patients with type II diabetes mellitus, hypertension and depression; improved management of asthma; and decreased all-causes of mortality.

The need for primary health care intervention can conceptually be defined as the ability or capacity to benefit from health interventions. These benefits may be in the form of an improvement, restoration, maintenance or protection of health status (Mustard & Derksen, 1997). For the purpose of this study, we have defined outcomes in terms of hospitalization for Ambulatory Care Sensitive Conditions (ACSC). These are conditions defined as, “(t)hose diagnoses for which timely and effective outpatient [primary] care can help to reduce the risks of hospitalization by either preventing the onset of an illness or conditions, controlling an acute episodic illness or conditions, or managing a chronic disease or condition” (Billings et al., 1993). Hospitalizations for these diagnoses may therefore indicate a potentially preventable complication resulting from limited access to responsive primary health care services. Further, the documented disproportionate rate of hospitalization for ACSC among First Nations when compared to other Manitobans (Martens, Sanderson, & Jebamani, 2005) suggests possible inequity in access to primary health care, and the need for investment. This indicator has been endorsed by researchers and policy makers as a dependable indicator of the performance of primary health care services (Canadian Institute for Health Information, 2006, Canadian Institute for Health Information, 2007, Marshall et al., 2004).

In the First Nation context, on-reserve primary health care services are funded and were historically delivered by the First Nations and Inuit Health Branch of Health Canada (FNIHB). Broadly speaking, the current complement of on-reserve health services is based on a 1969 study (Booz Allen & Hamilton Canada Ltd, 1969) that recommended a greater focus on prevention. This study’s recommendations however nested themselves in a federal policy that conceptualized the responsibility of the federal government as complementary to what services were available from provincial governments. What emerged is a four-level framework that constitute the basis of FNIHB funding of on-reserve health services, based on community size, level of remoteness and access to provincial services, as shown in Table 1. This is generally referred to as facility designation.

Communities considered to have reasonable access to provincial health care services in nearby communities are funded to offer screening and preventive services on a part-time basis (health offices). Communities located within a 2-h drive from provincial services are funded to ensure local access to preventive, screening and emergency care. These services, delivered through health centres, focus on primary prevention, with some level of secondary prevention interventions. There is no or limited funding to ensure off-hours coverage. More isolated communities served by nursing stations, are funded to ensure local access to screening, prevention, emergency and treatment services on a 24/7 basis, delivered by nurses with an extended scope of practice.

Previous work by Martens et al. (2005) documented that diabetes prevalence rates are 4.2 times higher for Manitoba First Nations compared to all other Manitobans, but the population prevalence of amputation due to diabetes is sixteen times higher (3.1 versus 0.19 per thousand, ages 20 through 79). The study reported the highest rate of amputations (6.2 per thousand) in First Nation communities located in the southwest of the province. Although there are some variations, these communities are considered non-isolated (meaning that a general practitioner and/or a hospital is available within 2 h, and that roads are passable all year), and served by either a health office (N = 5) or a health centre (N = 4). These findings suggest that geographical accessibility does not guarantee that services can be accessed, are accessed and/or are responsive. These findings provide an impetus to look more carefully at the relationship between local access to care and outcomes.

Since the late 1980s, FNIHB has developed mechanisms to facilitate greater First Nation engagement in priority setting, program planning and service delivery. Communities now have choices between three levels of community control: Transfer; Integrated; and Non-transferred/Non-integrated (NTNI). Flexibility depends on the model chosen by the community.

Under the Health Transfer approach, communities can take on the administration of a range of community-based and regional programs. The process includes the transfer of knowledge, capacity and funds so that communities can manage and administer their health resources based on their own community needs and priorities (Health Canada (FNIHB), 2004b). Financial and human resources are available for pre-transfer planning, for up to 21 months (Health Canada (FNIHB), 2004b). Following the completion of this planning period, and the development of a community health plan, communities may sign a three or five year agreement. Under these agreements, communities may design new programs and redirect resources to areas of high priority, as long as mandatory programs (immunization, communicable disease control, environmental health) are delivered (Health Canada, 2007). Funding is provided based on historical expenditures, to which is added some funding for administration. As a result of this additional funding, some communities are able to hire a full time Health Director from the community. This model became available to communities in 1989.

A community that chooses the Integrated Community-Based Health Services approach gains less control than with Transfer. Under the Integrated approach, a community sets up its own health management structure but shares responsibility for delivering services with FNIHB. Community funding is based on historical expenditures. Under this approach, communities may not create new programs outside the FNIHB mandated services. However, communities are able to make some program adjustments to reallocate resources, and to set up health management structures that receive funding on an on-going basis (Health Canada (FNIHB), 2004b). This model became available in 1994.

NTNI communities have some measure of community control, in that a limited number of programs are managed by the community, each under a separate contribution agreement. As a result, NTNI communities have little latitude in priority setting and in the strategic allocation of resources, but some say over implementation. Each program has its own funding formula that may be based on historical expenditures, proposal writing, etc. This model emerged in the late 1970s. Although the number of programs available under this option has increased over time, so have expectations.

Finally, as a result of an Agreement signed in 1964 by the federal and provincial Health Ministers, four Manitoba First Nation communities receive their clinical and public health services from Manitoba Health, through their local Regional Health Authority (RHA). In contrast, the on- and off-reserve population living in or close to fifteen other First Nation communities was designated as federal jurisdiction. The communities served by their RHA have no opportunity to engage in self-government activities.

Section snippets

Data and sample

The project sample includes all Manitoba residents eligible under the Manitoba Health Services Insurance Plan living on First Nation reserves (N = 64,933 in 1984/85; N = 71,510 in 2004/05). One conceptual impediment to pursuing this work to date has been that researchers have focused on ethnicity rather than residency in a community as the key independent variable. The current databases are unable to reliably show First Nation identification. This study however does not require First Nation

Local access to care

As shown in Table 4, our results show that the rates of hospitalization for ACSC in communities served by a nursing station are lower than the rate of ACSC in communities that have no health care facility at the local level, or that are served by a health centre or a health office (p < 0.05). These findings were consistent with our hypothesis.

Local control

We investigated whether the rate of hospitalization for ACSC hospitalization was different for the different categories of autonomy (provincial/RHA, NTNI,

Discussion

This study sought to document the relationship between local access to primary health care, measures of community control and the rates of hospitalization for ACSC in First Nations living on-reserve, in the province of Manitoba, Canada. We acknowledge a number of limitations to this study. First, we used locality (postal codes) as opposed to ethnicity to identify First Nations. As a result, it is likely that some non-indigenous individuals living on-reserve (employees, partners), and some First

Acknowledgements

The authors would like to acknowledge the participation of the Assembly of Manitoba Chiefs in the planning of this study, and the Chiefs Task Force for their assistance in the analysis of the data. We would also like to acknowledge the Canadian Institutes for Health Research and Manitoba Health who provided the financial support for this study. We are thankful for the assistance provided by the Manitoba First Nations Centre for Aboriginal Health Research and the Manitoba Centre for Health

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