A Dialogue on the Tripartite First Nations Health Plan

Transcription

1 A Dialogue on the Tripartite First Nations Health Plan November

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3 i TABLE OF CONTENTS BACKGROUND 2 EXECUTIVE SUMMARY OF THE 2009 FORUM 3 DAY ONE: HEALTH GOVERNANCE TUESDAY, NOVEMBER 3, KEYNOTE ADDRESS BY THE TRIPARTITE PARTNERS 6 TRIPARTITE GOVERNANCE COMMITTEE PROCESS 10 Q & A: Tripartite Governance Process 13 FIRST NATIONS INTERIM HEALTH GOVERNANCE COMMITTEE 14 Plenary on First Nations Interim Health Governance Committee 15 Q & A: First Nations Interim Health Governance Committee 17 HEALTH GOVERNANCE EXPERT PANEL 17 DAY THREE: HEALTH DIRECTORS - THURSDAY, NOVEMBER 5, HEALTH MANAGER NATIONAL ASSOCIATION 58 FIRST NATIONS HEALTH DIRECTORS ASSOCIATION 60 Review of Health Directors Survey Results 60 Review of Proposed Association Model 61 Q & A: First Nations Health Directors Association 61 Vote to Form First Nations Health Directors Association 62 Selection of Regional Representatives 63 Professional Development Workshops 63 REGIONAL CAUCUS DISCUSSIONS 21 BC CHIEF S UPDATE ON H1N1 24 Q & A: H1N1 25 DAY TWO: HEALTH ACTIONS - WEDNESDAY, NOVEMBER 4, ADDRESS BY FIRST NATIONS HEALTH COUNCIL 34 Q & A: Address by First Nations Health Council 35 ADDRESS BY TRIPARTITE PARTNERS 36 Q & A: Address by Tripartite Partners 40 LUNCH SPEAKER EDITOR PATHWAYS TO HEALTH AND HEALING 40 HEALTH EXPERTS PANEL 41 HEALTH ACTION UPDATES 45 Cultural Competency 45 Mental Wellness & Substance Misuse 45 E-Health & Data 46 Primary Health 47 Maternal & Child Health 47

4 II REFERENCE MATERIALS (Available at at Tripartite Governance Committee Presentation: Tripartite First Nations Health Plan Interim Health Governance Committee Presentation: Putting the Plan into Action: BC First Nations Health Governance. Health Governance Experts Panel Presentations: Alaska Tribal Health System: Introductions and Lessons Learned, Alaska Native Tribal Health Consortium. Indigenous Health Governance Helping Build Appropriate and Resilient Governance Structures for Improved Well-Being and Health Outcomes. Regional Caucus Position Paper: Northern Chiefs Meeting on Health Governance, October 19 and 20, 2009, Northern BC First Nations Issues, First Nations Interim Health Governance Committee Northern Region. H1N1 Presentation: H1N1 and First Nations in BC First Nations Health Council Presentation: Gathering Wisdom for a Shared Journey III Luncheon Presentation: Pathways to Health and Healing Health Expert Panel Presentations: Community Hubs, Turtle Island Thinking about Indigenous Health Service Models Health Actions Updates: Update on Mental Health and Substance Use Primary Health Gathering Wisdom Day 2 Maternal Child Health Gathering Wisdom for a Shared Journey III Health Directors Association Presentations: First Nations Health Manager National Association Advisory Committee (FNHMAC)

5 gathering wisdom for a shared journey a dialogue on the tripartite first nations health plan november 3-5, 2009

6 2 Background In March 2005, the Province of British Columbia and the First Nations leaders agreed to enter into a New Relationship guided by principles of trust, recognition and respect for Aboriginal rights and title. The New Relationship focuses on closing the gaps in quality of life between First Nations and other British Columbians. In November 2005, the Province of British Columbia, the First Nations Leadership Council and the Government of Canada signed a historic agreement entitled the Transformative Change Accord. The Accord recognizes the need to strengthen relationships on a government-togovernment basis, and affirms the parties commitment to close social and economic gaps in health, education, housing and infrastructure, and provide economic opportunities through a comprehensive ten year implementation strategy. As per the Accord, the First Nations Leadership Council and the Province of BC developed a ten-year plan for health, the Transformative Change Accord: First Nations Health Plan, in late The Government of Canada, via Health Canada, entered into a First Nations Health Plan Memorandum of Understanding with the First Nations Leadership Council and the Province of British Columbia on November 27, The Transformative Change Accord: First Nations Health Plan and the First Nations Health Plan Memorandum of Understanding are two key documents that identified priorities and actions items to fulfil the goal of closing the health gaps between BC First Nations and other British Columbians. The action items guide the tripartite efforts to address critical challenges that must be overcome in order to deliver on the joint commitments to improve the health and well-being of First Nations. messages received from participants at the first Annual First Nations Forum: Gathering Wisdom for a Shared Journey held in April 2007, which identified a number of challenges and opportunities and priorities for action including the establishment of the First Nations Health Council. Central to the Plan is a commitment to create a new governance structure that will enhance First Nations control of health services, and will promote better integration and coordination of services to ensure improved access to quality health care by all First Nations living in British Columbia. As described in the First Nation Health Council s Year in Review Report 2009 the work of implementing the Tripartite First Nations Health Plan calls for action in four areas: Governance, Relationships and Accountability; Health Promotion, Disease and Injury Prevention; Health Services; and, Performance Tracking. The First Nations Health Council will continue to work with First Nations communities, government partners and other stakeholders to shape and implement the Tripartite First Nations Health Plan in ways that respond to community needs and circumstances. The information contained in this report will be provided to both the First Nations Health Council staff and First Nations communities and leadership to assist in identifying appropriate modifications to work plans and contribute to the design of the next Annual Gathering Wisdom forum. A key deliverable of the tripartite First Nations Health Plan Memorandum of Understanding was the development of the Tripartite First Nations Health Plan, signed on June 11, The Plan was informed by the MOU, and by key gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

7 3 Executive Summary of the 2009 Forum The third Annual Gathering Wisdom for a Shared Journey Forum, or GWIII as it is often referred to, took place over three days: November 3-5, The goal of the forum involved creating discussion around three key themes: Health Governance (Day One); Health Actions (Day Two); and, Health Directors Association (Day Three). Day One Health Governance: Putting the Plan into Action On November 3, 2009, the Government of Canada, Government of BC, and BC First Nations Chiefs and health leads engaged in discussions on several areas including: keynote addresses by the Tripartite Partners; Tripartite Governance Committee Process; First Nations Interim Health Governance Committee; and, Regional Caucuses. Day One also included a Health Governance Expert Panel to discuss key comparative health governance models, such as the United States indigenous health governance model in Alaska. In addition to the important governance items covered on Day One, the BC Chiefs also received an update on the H1N1 influenza epidemic. Highlights of the Governance Day included: Reaffirmation of the tripartite partners commitment to the plan as a critical means of increasing First Nations control over health, and improving the health of First Nations in BC to a level comparable to other British Columbians. Recognition of the concerns about entering into an agreement in principal about the governance structure, and clarification of how the agreement would guide the further development of an effective governance model. Recognition by the partners that developments be responsive to community diversity as well as community driven. Acknowledgement of the importance of demonstrating progress at all levels within the Tripartite Health Plan on an ongoing basis by all participants. Impressive demonstrations of First Nations capacity to manage the tripartite approach within the health system occurred with the Interim Health Governance Committee members facilitated regional caucuses; and Indigenous physicians from BC First Nations communities presented the government updates on H1N1. Day Two Health Actions: Update on the Transformative Change Accord and Tripartite First Nations Health Plan On November 4, 2009 (Day Two), the twentynine action items captured in the Transformative Change Accord, Transformative Change Accord: First Nations Health Plan and verified by the Tripartite First Nations Health Plan were the focus. The importance and progress made on the action items since 2008 were discussed through updates by the First Nations Health Council, Tripartite Partners, and a Health Experts Panel. Day Two`s lunch hour provided an opportunity for participants to receive an overview of the provincial Pathways to Health and Healing report. Highlights from the Health Actions day included: Introduction of the founding members of the First Nations Health Society Board of Directors. The community engagement hubs provided a presentation on the efforts of FN communities coming together to collaborate, communicate and plan on health. First Nations led discussions of tripartite partnership in action. Panel presentation on lessons to be learned from other successful models of indigenous control of health services delivery (e.g. Maori and Alaskan Native). Breakout sessions provided updates in the areas of Mental wellness & Substance abuse; e-health & Data; Primary health; Maternal & Child health; and Cultural competency. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

8 4 Day Three Health Directors: Association and Professional Development On November 5, 2009 (Day Three), the discussions focused on the work that had been done over the previous year to develop a First Nations Health Directors Association. The participants discussions involved an examination of the work to establish a National Association s Health Managers, a review of the results of the BC First Nations Health Directors Survey and how it had been developed into a proposed Association model. The participants voted to ratify the Association, and met in regionally based break-out sessions to select regional representatives for the Association s founding board of directors. Highlights of the Health Directors day included: Creation of the Health Directors Association, one of the governance structures called for in the Tripartite First Nations Health Plan, was confirmed by an 87% in favour vote for the model presented at the Gathering Wisdom Forum. Conclusion The GWIII forum was an opportunity for community dialogue on the implementation progress of the Transformative Change Accord and the Tripartite First Nations Health Plan. It provided First Nations with another avenue for input, and perhaps most importantly an opportunity for participants to learn from one another. In the more detailed synopsis of the Gathering Wisdom Forum contained in this report you will find summaries from each of the speakers, results of separate group discussions and a list of reference materials related to the Forum. It provides a wealth of information and insights on how this tripartite approach can make a difference in the health of First Nations people in BC. In addition to being a valuable communications tool, this report will be utilized in the ongoing efforts to implement the Tripartite First Nations Health Plan, and to plan for future gatherings. Use of caucus sessions to identify the preliminary list of names for the founding board of Directors for the Association. Convening 4 professional development workshops to respond to the Health Directors priority on building the capacity of First Nations health professionals and managers. gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

9 day one: Health Governance putting the plan into action november 3, 2009 Day One was moderated by Harold Tarbell, Facilitator and Richard Jock, Health Governance consultant. Elder Leonard George, Tseil Waututh First Nation opened the forum with a prayer, song and words of encouragement. In essence he urged that we give ourselves permission to move forward and exercise our jurisdiction in health with the wisdom gathered at this conference; to hold ourselves accountable to our culture; and apply all of this in the service of assisting our people regain the high quality of life to which we were once accustomed.

10 6 KEYNOTE ADDRESS BY TRIPARTITE PARTNERS The Honourable Leona Aglukkaq, Minister of Health, Government of Canada Working Group, Co-Chaired by two First Nations physicians, has been responding to the pandemic in BC and developed an action plan specific to BC First Nations. As the second wave of H1N1 pandemic approached in 2009, the Minister had confidence that the leadership in BC would continue to manage the situation and minimize its consequences. The Minister advised that BC First Nations physicians played a crucial role in the H1N1 action plan. She commended the efforts of Dr. Evan Adams, the Aboriginal Health Physician Advisor to the BC Health Office and Dr. Shannon Waters who co-chaired the H1N1 Health Partners Group in an effort to help First Nations communities prepare for the next wave of the virus. Minister Aglukkaq welcomed the Annual Gathering Wisdom Forum as an opportunity for the tripartite partners to reflect on what has been achieved over the past few years in BC First Nations health, and the possibilities there are in the near future to improve BC First Nations health so that it is comparable to that of other British Columbians. The future success, she acknowledged, will depend on how effectively BC First Nations, federal and provincial governments work together. The Minister expressed that she relates to the unique health challenges of BC First Nations in small and remote communities because there are very similar issues experienced within her own Inuit community. She supports changing the way that BC First Nations health is currently governed as a means to improve health services, as well as health promotion and disease prevention initiatives in a manner that allows First Nations to play a larger role in the design and delivery of their own health. The Minister noted that the handling of the H1N1 issue was an indication of how the Tripartite Health Plan was being implemented and contributing to improving on BC First Nation s health issues. The Tripartite H1N1 When the BC First Nations Tripartite Health Plan was signed in 2007, we all agreed to work together to develop a new model for a new First Nations health authority within three years and through our mutual commitment and partnership I am confident it will be achieved. The Hon. Leona Aglukkaq The Minister expressed her confidence that efforts in health governance are setting the groundwork for new health care partnerships with greater control by BC First Nations; a mechanism that will lead to long term health care improvements. The creation of a new First Nations health authority is an important aspect of the governance agreement. It involves a First Nations entity taking over Health Canada s regional office responsibilities with respect to First Nations. A key point expressed was that although the governance agreement will give greater authority to BC First Nations in the gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

11 7 management of their own health, it will not take away from activities of First Nations that have already begun to deliver their own health services. Rather, the intent of the governance agreement is to draw from experiences and support health plans of individual First Nations, while Health Canada continues to fund health programs. An added element of change would be that First Nations would decide which programs meet their specific needs. The Minister recounted her experience serving as Health Minister when her own territory was undergoing the daunting task of assuming governance of health. The innovative change was a major step in providing health services for First Nations by First Nations people. New approaches to health care are innovative, and in BC there is a groundbreaking opportunity to demonstrate vision, courage and commitment to work as tripartite partners to reach an agreement that will improve the health of BC First Nations and impact the whole country. The Minister concluded expressing her confidence that the tripartite commitment set out in the 2007 BC Tripartite First Nations Health Plan, to develop a new model for a new First Nations health authority, would be achieved. The Honourable Ida Chong, Minister of Healthy Living and Sport, Government of British Columbia Minister Chong expressed BC s continued commitment to the Tripartite First Nations Health Plan and resulting goal of creating a new governance structure for First Nation health. The Minister acknowledged that a new governing structure for BC First Nations health would be a milestone that other provinces and jurisdictions could aspire to. She added that the province recognizes its role as partner in the tripartite process of changing how decisions are made and health services are provided to BC First Nations so that BC First Nation input is meaningful. We all want to see the tripartite plan and goal of creating a new structure for First Nations Health in the province. It will be a milestone for other jurisdictions to look to. The Hon. Ida Chong Specific concerns referenced by Minister Chong were the importance of improving coordination of on and off reserve health services and implementing culturally appropriate health care, prevention programs and policies for the delivery of health care to BC First Nations. The Minister comitted her, and her senior health staff s, time and resources to contribute to making better coordination a reality. The Minister agreed the coordination of the H1N1 pandemic plan, made possible because of the partnerships arising out of the Tripartite First Nations Health Plan, was a success story. The Minister further confirmed the province s commitment to achieve a governance agreement with BC First Nations and the government of Canada, and acknowledged that it would be a valuable tool to eliminating the health gaps between First Nations and other British Columbians. She stressed the governance structure will only be successful if each tripartite party is comfortable with the terms of the agreement and receives the support of all the partners involved while details of the agreement are resolved. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

12 8 In her concluding remarks, Minister Chong reiterated BC s commitment to partner with First Nations leaders to improve First Nations control over First Nations health related decisions. In this respect, the strong efforts of First Nations leaders and their collaboration with the federal and provincial governments was acknowledged in their movement towards common and important goals of improving BC First Nations health. Grand Chief Doug Kelly, Co-Chair First Nations Interim Health Governance Committee Chief Kelly welcomed participants and government partners acknowledging their time, energy and commitment to creating healthy, self-governing and self-determining First Nations. He encouraged participants to share their knowledge and expertise about how the current health governing system works and doesn t work, and how First Nations cultural practice could be incorporated. The Grand Chief expressed that the purpose of the annual Forum involves learning from one another. not be funded to fail. It is difficult to meet the expectations of First Nations people living at home or away from home, in the absence of adequate resources. Therefore, an understanding was needed of the resources and funding required making a new First Nations governing structure work. A team is currently carrying out work in an effort to address the specific issue of what it will take for First Nations to govern First Nations health in BC. Grand Chief Kelly expressed that an agreementin-principle is being discussed at the governance table. Agreements-in-principle are often made between parties in business to generally describe the parties, opportunities and how the work would go forward to complete a project or activity. The initiative to come to a health governance agreement, arises out of the Tripartite First Nations Health Plan. He expressed that First Nations traditions and inherent rights should be incorporated into the governance agreement. Grand Chief Kelly acknowledged that First Nations must make decisions and that the Ministers have an appreciation for the understanding that needs to be reached. Funding is a critical principle in a potential governance agreement as First Nations should gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

13 9 One of the components of the agreement we will be looking to is funding. No one wants to be funded to fail. Grand Chief Doug Kelly First Nations to discuss the tripartite initiative and to ensure First Nations directions are being respected in health governance. In his summation, the Grand Chief expressed his thanks to the Ministers, particularly Minister Chong, for her comments and commitments. Grand Chief Kelly encouraged participants to consider certain questions: What belongs to First Nations? ; What are the programs to share with a regional organization? ; and, What work should be shared at regional, provincial and national levels?. A key question, What is the authority of our authority is one that can only be answered by First Nations. In answering the above questions, he expressed that it is critical to address the cynicism, doubt and anxiety that arises when discussing change. He expressed that it is necessary to create opportunities that improve health in First Nations, specifically northern and isolated communities, which are currently struggling to access health services. The Grand Chief gave specific examples such as the inaccessibility of patient transportation and medical personnel to many BC First Nations citizens. He supports the demonstration of First Nations governance by participation in making decisions and positive changes that are needed to improve BC First Nations health concerns. In the effort to make change, he noted his commitment to continue to travel to many v a n c o u v e r, british c o l u m b i a november 3-5, 2009

14 10 TRIPARTITE GOVERNANCE COMMITTEE PROCESS Joint Presentation: Tripartite First Nations Health Plan Grand Chief Doug Kelly, Co-Chair, First Nations Interim Health Governance Committee Ian Potter, Project Manager, First Nations and Inuit Health Branch, Health Canada Grand Chief Doug Kelly, Co- Chair, First Nations Interim Health Governance Committee A new First Nations health authority will measure our progress and identify areas of needed attention through agreed upon tripartite processes of reciprocal accountability and transparency. The Tripartite First Nations Health Plan recognized that things had to change, that change needed to be made in the structure, administration and control of health services. Andrew Hazelwood introduced the joint presentation, which traced the progress of the relationships of BC First Nations with federal and provincial governments since BC Premier Campbell s commitment to establishing the New Relationship signed in March The commitment led to the develoopment of the First Nations Leadership Accord and prompted a focus on the vision of health from a First Nations perspective in BC. The tripartite partners went through the history of the Transformative Change Accord, Memorandum of Understanding, Transformative Change Accord: First Nations Health Plan and Tripartite First Nations Health Plan. In the joint tripartite presentation, Grand Chief Doug Kelly stressed that the Tripartite First Nations Health Plan is a commitment to implementing a ten-year health plan involving four key elements: governance, relationships and accountability; health promotion/ injury and disease prevention; health services; and performance tracking. In the implementation of this governing structure, Grand Chief Kelly expressed that it is important to define First Nations inherent right of self-government and to determine how First Nations would work with others in BC and across Canada. In turn, Ian Potter recognized that the Tripartite First Nations Health Plan represents a change that is needed for First Nations to gain more control over their own health services, and that all three parties are required to work together on principles regarding how the future will unfold. He indicated gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

15 11 Andrew Hazelwood, Assistant Deputy Minister Ministry of Healthy Living and Sport The Transformative Change Accord recognized that there was a gap to be closed, not just a gap in health, but in education, housing, economic opportunities and health. that a potential agreement could include principles that BC First Nations, Health Canada and the province are committed to implementing: respect for cultural knowledge and traditional healing; respect for diversity; commitment to effective working relationships; no duplication or creation of parallel health system; commitment to reciprocal accountability; and, open and timely information sharing. Grand Chief Kelly explained that many of the health programs currently being delivered to BC First Nations were designed in Ottawa and Victoria, or by those responsible for services in various geographical authorities. Therefore, it is critical to ensure that First Nations have a place at the table and continue to build capacity and expertise to design programs and services for First Nations. In changing the health governance system, it is important to turn health governance from a sickness system into a wellness system. Performance tracking of a wellness system would focus on the improvement of the health and well-being of First Nations families and communities, and First Nations institutions that influence federal and provincial policy related to social determinants of health such as housing, infrastructure, employment, training, education, languages, and health. The tripartite partners reviewed some of the structures being developed under the Tripartite First Nations Health Plan. Andrew Hazelwood explained that the First Nations Health Council incorporated v a n c o u v e r, british c o l u m b i a november 3-5, 2009

16 12 the Health Society to act as its business and operational arm. The Provincial Committee on First Nations Health meets annually and includes the participation of the CEO s of the regional health authorities; thus providing an opportunity to discuss and report on the progress of First Nations organizations service plans. First Nations senior leaders and the provincial health system are coming together to discuss goals and objectives and to identify ways to work together. Hazelwood explained that the First Nations Health Directors Association is a group of health care professionals, with expertise in providing services to First Nations communities. He also explained that the First Nations Health Governing body (or First Nations Health Authority ) is being created to manage and direct services provided by Health Canada through First Nations Inuit Health. He discussed that the implementation, authority and responsibility of the First Nations Health Authority will need to be discussed at the Gathering Wisdom Forum and in the future. Ian Potter commented that within the structure of the BC Tripartite Governance Committee, First Nations representatives on the Committee are assisted by the First Nations Interim Health Governance Committee. Mr. Potter acknowledged that the new BC First Nations health governing structure must be founded on BC First Nations definition of health; be accountable to BC First Nations; reduce bureaucracy and maximize services; prioritize according to BC First Nations health plans; support comprehensive public health, promotion/ prevention and primary health services and clearly ensure BC First Nations authority and jurisdictions; and, work closely with provincial health authorities and the BC health system to improve health. In the creation of a new BC First Nations Health Governing Body, Grand Chief Kelly reviewed several key elements that the new First Nations Health Authority would respect, support and augment; for example, the current delivery of health programs by BC First Nations and their mandated health organizations. First Nations would initially take over the current delivery of health programs to BC First Nations [from Health Canada First Nations Inuit Health, Pacific Region]. As confidence in First Nations was gained, then steps would be taken to design First Nations-specific programs and services, based on what First Nations believed were needed to make a difference. The First Nations Health Authority will recognize progress, a reciprocal accountability process, and transparency. Grand Chief Kelly noted that it is critical to ensure that institutions and mechanisms are created with the ability to influence determinants of First Nations health. First gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

17 13 Nations should be organized to provide direction and advice on how government deals with First Nations investments. It is important to organize and coordinate First Nations councils with the efforts of Chiefs, leaders, and directors of delegated agencies to work effectively with educational and other programs. Mr. Potter acknowledged his understanding that a new BC First Nations health governing structure will be founded on First Nations values and the importance of community. A clear and defined role for First Nations involvement within the health system is required, and the First Nations authority needs to be spelled out. Mr. Hazelwood advised that further information can be sought from any of the tripartite partner representatives (i.e. First Nations Health Council, Ministry of Healthy Living and Sport, and Health Canada). The Principal members of the tripartite partners are elected officials who have agreed to meet to discuss the tripartite agreement. Both the Ministers, and First Nations elected representatives, have been meeting to discuss areas of the new plan and the new governance structure; and they are scheduled to meet again in December 2009 (subsequently rescheduled to January 2010). The Tripartite Governance Committee has met monthly, conducted community consultations and scheduled time to continue the efforts in the future. Q & A: Tripartite Governance Committee Process A number of issues arose concerning the quick pace that BC First Nations are entering into an agreement-in-principle with Health Canada. Specific concerns involved the issue that a change to the BC First Nations health system will take time so as to ensure that all BC First Nations agree with its direction. The tripartite partners clarified that the agreement-in-principle would establish criteria, be an assessment tool, and a means for First Nations youth, Elders, health directors and others to determine if they have done a good job in creating a governance model. An actual governance model will not be complete after two months. Rather, it is an action plan that sets out clear guiding principles about how to work amongst each other to define a governance structure that will be complete. The tripartite partners also stressed that it was important for First Nations to be well informed and make decisions they feel comfortable with. It was discussed that the agreement-in-principle can clearly set out expectations in terms of consultation, and an approval process. The tripartite partners assured that they will move carefully and slowly to deal with funding; and, deal with defining relationships over the coming months and years. Further, they will discuss demonstration projects that can immediately improve First Nations health. Additionally, the tripartite partners suggested that we should not wait longer than necessary to respond to First Nations needs. There is benefit in striking a balance between understanding and moving ahead. The federal government and First Nations are proposing that new relationships open at the local level in order to move forward. In the new governance model, there is no intention that the federal government would abandon its overall responsibility. The change would be that health services currently provided by Health Canada would be provided under a First Nations Health Authority. In terms of the approval process for an agreement-in-principle, who would sign off on behalf of BC First Nations was in issue. The discussion stressed the importance that approval occur at the community level. The participants were assured that resolutions have been secured from the BC Assembly of First Nations, the First Nations Summit and BC Union of Indian Chiefs that endorse a sign-off on the agreement-in-principle. The expressions of concern by First Nations that do not support those organizations will need to be worked out in the approval process for the final outcome; a process that has not been defined yet. The tripartite partners emphasized that an agreement-in-principle would not lay out a final v a n c o u v e r, british c o l u m b i a november 3-5, 2009

18 14 document, rather a clear way to outline the changes that Canada, BC and First Nations will strive to achieve. Particularly, importance was placed on changing the design of policies and programs, and securing investments from Canada and BC to address gaps in health provided to BC First Nations. Issues involving funding commitments arose in the discussion; it was considered important to ensure that an administrative arrangement is reached that is adequately funded. There was discussion that existing services to BC First Nations have not been adequately funded, and existing funding levels should not be the starting point of an agreement-in-principle. There was recognition in moving forward to the next phase, there should be greater investments by the governments, especially in the areas of Non-insured Health Benefits and supporting successful initiatives. Issues related to equitable funding for the Pacific Region are expected to be addressed with the negotiations. The importance of building relationships with providers was an issue and it was suggested that First Nations must communicate with pharmacists, medical colleges, and professional associations who make economic decisions without necessarily understanding First Nations issues. Improving the relationship with providers can result in the development of strategies that creatively address BC First Nations health needs. The tripartite partners concluded the question and answer period discussion with the encouragement that information regarding funding to be transferred to a First Nations Health Authority will be available to anyone who wants to see it. At Health Canada, there is an accountant currently pulling together numbers into a presentation. In addition, the First Nations Health Council has hired consultants to review the information as well. Finally, the information will be open and transparent to everyone. FIRST NATIONS INTERIM HEALTH GOVERNANCE COMMITTEE PROCESS Grand Chief Ed John, Co-Chair, First Nations Interim Health Governance Committee All our 203 communities in this province have concerns about our people s well being and although the concerns may vary slightly from community to community, we are faced with the same challenges in accessing health services for our people. Grand Chief Edward John opened with acknowledgment of the involvement of the federal Minister Aglukkaq and provincial Minister Chong in ensuring First Nations were on the priority list for access to H1N1 vaccines. Grand Chief John referenced concern about the well-being of all 203 BC First Nations and the critical importance of every BC First Nation having a community health plan in place. A common concern is the difficulties all First Nations have in terms of access to health care; including services in major hospitals and BC Care Card entitlements. It is crucial that the province and its health authorities are engaged in ensuring that services are provided to each gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

19 15 community, and based on the community s respective health plans. Grand Chief John noted that the structure of a governance body, its accountabilities and authorities, should be representative of all First Nations in the province rather than imposed upon them. In order to build a strong and solid foundation, First Nations would need resources to develop a First Nations governance structure that is representative of all BC First Nations communities. Plenary on First Nations Interim Health Governance Committee Chief Bob Chamberlin, First Nations Interim Health Governance Committee, Vancouver Island Regional Member Grand Chief John discussed his understanding that the federal government would be reviewing financial issues of its departments by January He acknowledged that the importance of making sure that resources needed in BC First Nations are not cut. He added that federal fiscal resources in question are yet to be determined. It was noted by Grand Chief John that the two hundred and thirty employees at First Nations and Inuit Health Branch, are represented by CUPE, the federal employer s union, for which a collective agreement is in place. Further, in the change of authority, the fiduciary obligations of the government would also need to be factored into any arrangement agreed to between First Nations and the federal government. In his conclusion, Grand Chief John extended his thanks to the First Nations Health Council for their efforts, and expressed that he looked forward to further discussion regarding what could collectively be done throughout the province. Presentation: Putting the Plan into Action: BC First Nations Health Governance. This is about moving forward and seizing an opportunity that has never been in place for us. Chief Bob Chamberlin explained that First Nations receive both provincial and federal health services, but currently have minimal control over the design and delivery of those services. Programs and services were generated without First Nations community health and wellness plans. He added that a new governing structure was needed to feed into decision making and to support First Nations regional engagement. Chief Chamberlin acknowledged Health Canada s interest in moving forward in a meaningful way. In these efforts, he expressed the importance of ensuring that directions were driven by First Nations communities. In the goal of redesigning a First Nations health care system, Chief Chamberlin expressed that efforts would need to be made to determine how information should be captured at the community level, v a n c o u v e r, british c o l u m b i a november 3-5, 2009

20 16 brought to the Regional Caucuses, and then to the BC First Nations Health Governance Committee. The Tripartite First Nations Health Plan committed to ensuring that BC First Nations and mandated health associations would each have a comprehensive health plan. Chief Chamberlin specified that health services delivered by First Nations, when appropriate, should be linked to and coordinate with provincially-funded services. First Nations health services should be delivered through a new governance structure which could lead to improved accountability and First Nations control of health services. Chief Chamberlin explained that the Tripartite First Nations Health Plan, called for a new First Nations structure for First Nations health services in BC with four essential components: the First Nations Health Governing Body; the First Nations Health Council; the Provincial Committee on First Nations Health; and, the First Nations Health Directors Association. Chief Chamberlin further explained that the Tripartite First Nations Health Plan called for two simultaneous processes: firstly, to deal with the health action items contained in the Transformative Change Accord; and secondly, to deal with governance items contained within the Tripartite First Nations Health Plan. He indicated that the First Nations Health Council, the First Nation Health Advisory Committee, and the Association of Health Directors were separate processes, and, were intended to support the overall objectives of implementing the tripartite agreements listed above. The First Nations Interim Health Governance Committee includes representation by Union of BC Indian Chiefs, the First Nations Summit, and the BC Assembly of First Nations. The Governance Committee was a sub-committee of the First Nations Health Council, and had been given the task to consider, develop, ratify and implement a new First Nations Health Governing Body. Chief Chamberlin confirmed that not all members of the Governance Committee were Chiefs the members were identified as the best suited individuals to serve on behalf of their respective regions. As part of this obligation, the Governance Committee will work in a tripartite process with representatives from First Nations and Inuit Health (Health Canada) and the BC Ministry of Health. Chief Chamberlin noted that the Governance Committee Co-Chairs (Grand Chief Edward John representing the First Nations Summit, Grand Chief Doug Kelly representing the BC Assembly of First Nations, and Chief Shane Gottfriedson representing the Union of BC Indian Chiefs) have made every effort to include and dialogue with BC First Nations leadership to ensure full engagement. Regional Caucuses were established, in order to gather the voices of BC First Nations in the North, Interior, Fraser, Vancouver Coastal and Vancouver Island. Each Caucus defined its own membership and appointed representatives to the common table. He informed the Forum that the new BC First Nations Health Authority would represent a new administrative arrangement between BC First Nations, BC and Canada. The process would not affect present or future treaty negotiations or Aboriginal rights and title discussions, and would not diminish federal fiduciary responsibilities. Chief Chamberlain described the 2009 First Nations Health Council incorporation of the First Nations Health Society; an interim structure that works with BC First Nations to ensure transparency and accountability, improve efficiencies, and carry out the implementation of the Transformative Change Accord: First Nations Health Plan and the Tripartite First Nations Health Plan. In September 2009, Chief Chamberlain informed that federal Minister Aglukkaq and provincial Minister Chong met with the First Nations Health Council and First Nations Interim Health Governance Committee Co-Chairs and Regional Members to renew commitments to the Transformative Change Accord: First Nations Health Plan and the Tripartite First Nations Health Plan. He added that Health Canada was keen to advance health governance negotiations with the First Nations Interim Health Governance Committee towards an agreementin-principle by December 2009 (subsequently postponed to January 2010). gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

21 17 Chief Chamberlin stated that First Nations have a tremendous opportunity to find solutions and to develop strategies that will reflect First Nations cultures, resiliency and strength. The First Nations Interim Health Governance Committee and the Regional Caucuses are organizing themselves to ensure that all BC First Nations are involved in the process of engagement and dialogue, and have the opportunity to express concerns, interests and questions about health and governance. He stressed that the First Nations Interim Health Governance Committee and BC First Nations will not be involved in any process that transferred the status quo of First Nations and Inuit Health and they would engage with First Nations governments on the basis of the inherent right to self-government. Chief Chamberlain added that in developing a health governance process that is community based and driven, it is critical to focus on children and families and work through political differences. He noted that small and remote First Nations need the most help. Further, he stressed the importance of getting clear information out to the regions, as First Nations are best at designing their own health services. whom. Therefore, he encouraged that if work needs to be done to clarify representation, then it needs to be taken care of at home. Grand Chief John encouraged each region to have people in place to speak to the issues that they want to have addressed. The discussion expanded on the nature of a governance agreement. The administrative role of the BC First Nations health governing model was clarified. Further, that the governing body would be put together based on direction and consultation with BC First Nations each Nation s rights and title being respected. HEALTH GOVERNANCE EXPERT PANEL Valarie Davidson, Senior Director Alaska Native Tribal Health Consortium Alaska, United States Q & A: First Nations Interim Health Governance Committee The issue of ensuring fair representation arose in participants discussions. Grand Chief Ed John explained that he had visited First Nations throughout BC and listened to concerns about representation. In particular the Gitxsan Health Authority has invited him to visit. He explained that the area is often cut off from Prince George and not properly represented. Grand Chief John suggested using feedback from other health authorities that have been successful to connect with the Gitxsan First Nation. Grand Chief John explained that the First Nations Health Council staff helps to coordinate his visits to BC First Nations. In the process of selecting representatives for the regional caucuses, he clarified that it was done by the regions. The First Nations Interim Health Governance Committee does not determine who speaks for Presentation: Alaska Tribal Health System: Introductions and Lessons Learned, Alaska Native Tribal Health Consortium. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

22 18 We share our agreements and negotiations happen in the open. We recognize we are unique and recognize the sovereignty of each tribe. Valarie Davidson described the role of the United States Indian Health Service (IHS) to provide health care to members of federally recognized tribes and their descendents, in recognition of a government-to-government relationship between tribes and the United States. This is done through a variety of delivery models including IHS providing direct care and tribally delivered care. In Alaska, the health system is tribally operated. The health care provided in Alaska native communities is provided by the Alaska Tribal Health System. Many health care providers speak traditional languages that are unique to the communities they work in; in addition, translation services are also available. The Alaska Tribal Health System is the public health system in Alaska, and is twice the size of the state-wide program. Alaska natives represent 20% of Alaska s entire population, and have a median range of 23.6 years compared to the 32.4 years for all Alaskan citizens. The leading cause of death of Alaskan natives is attributed to the significant changes in diet over recent years. Ms. Davidson added that the average Alaskan village has a population of 350 people. Under the old health system, health care was provided out of a shack; new clinics have been built with local construction hires. In a review of the Alaskan health facilities, it was noted that the Alaska Native Tribal Health Consortium also managed sanitation facilities. Ms. Davidson indicated that infants in communities without adequate sanitation were more likely to be hospitalized for respiratory infections and skin infections. The only level two trauma centre in Alaska was the Alaska Native Medical Centre. The Centre has one hundred and fifty beds, two hundred and fifty medical staff, over seven hundred nurses and an operating budget of over two hundred and fifty million dollars. The Alaskan tribes negotiate as a block with a whole week dedicated to negotiations. The result applies to every federally recognized tribe and all co-signers agree to a common compact. If one person doesn t agree, then discussions continue until everyone understands the issues. Information and analysis is shared with all tribes and there is clear understanding of the parties regarding agreements made. Ms. Davidson added that contract support funds with the US system allocates resources to invest in operations and infrastructure. If services aren t available through a tribal service, care is purchased from a non-tribal service. She noted that it is important to have co-lead negotiators with the ability to speak on behalf of the caucus. If I could leave you with one thing, it s that all the questions and concerns you have is where we were twenty years ago... at the time it was a tremendous leap of faith. Davidson indicated that similar questions and concerns like those expressed by participants of the Gathering Wisdom Forum, were expressed when the Alaska Native tribes began to take over control of health delivery twenty or thirty years ago. Ten percent of the people were eager, ten percent were opposed, and eighty percent said Let s see how this goes. Funds were available at the time and it took a leap of faith. Ms. Davidson concluded her Day One s discussion by indicating that everyone needed to be heard and there was no one more accountable for First Nations health care than First Nations. She reminded participants that nothing was impossible. gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

23 19 Manuhuia Barcham, PhD, Synexe Consulting Ltd., Palmerston North, New Zealand Presentation: Indigenous Health Governance Helping Build Appropriate and Resilient Governance Structures for Improved Well-Being and Health Outcomes. Planning is figuring out where we re going to go, how we re going to do it, what worked, what didn t and this is a cycle. Dr. Manuhuia Barcham defined governance as the operation of the structures and processes that groups used to achieve their goals; and development as the achievement of the aims and aspirations of individuals and communities. Dr. Barcham explained that mortality rates are important when talking about governance, but are only part of a broader range of issues to be addressed. There is not one goal of development for all the people in the world, and there isn t one governing structure to get there. The different processes to achieve these goals will depend on First Nations communities traditional structures. He stressed that a model from one place could not necessarily be applied the same way somewhere else. However, there are lessons that First Nations can learn from one another s mistakes; and successes that First Nations can build on. Dr. Barcham noted the importance of First Nations building on their investments for generations to come, and continuing to work towards appropriate structures and processes. He suggested that the success and failure of Aboriginal health in BC was pivotal to the success and failure of British Columbians in the province. Dr. Barcham discussed the large number of the tribes in New Zealand and he reported that lifestyle disease rates (i.e. obesity, diabetes, etc.) were high and an area requiring action. He explained that health services provision is pushed down from the Ministry of Health to district health boards. Tribal people are situated across a large area over six different municipal councils and four district health boards. Over the past three years, efforts have been made to push towards an integrated care model, mapped onto traditional boundaries. Additionally, Dr. Barcham described a program that has been created to reconnect who Tribal people are, which requires breaking down the organizational structures of ministries (including those focused on sports, culture, health, education, and schools) to enhance collaboration. A large structure was needed so that all stakeholders could come together to determine how to move forward. In his conclusion, Dr. Barcham discussed pursuing a holistic approach, while abiding by the words of Tribal Elders. He reminded participants that planning, monitoring, and evaluation needed to be done in a culturally appropriate, sustainable and integrated way. Further, information was needed to help guide what was working and what was not. In addition, funding decisions need to be made, and the voices of communities needed to be heard. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

24 20 Paul L.A.H. Chartrand, Consultant Saskatoon, Saskatchewan broader-based political strategy. For example, there is background political action asserting the right of self-determination. In exercising the right of self-determination, it is important to consider what creates happy and healthy neighbourhoods. Mr. Chartrand discussed that the Canadian government is organized by sectors and mandates. First Nations are aggregated as communities to a provincial organization, and he suggested that aggregation increases effectiveness. In embarking on agreements, it is important to realize what is being done now, and what has not been done before. He noted that First Nations typically proceed with caution. Paul Chartrand advised that comparative studies were important, as they provided direction on what to do and what not to do in varying situations. A solution that works in one situation may not work in another. He explained that although he is not an expert in health, in the area of governance he has published papers in various countries and worked with the United Nations. Further, he has been briefed on specific health issues by various provincial government representatives, and has listened to Indigenous people from around the world. He noted that the pending Agreement-in- Principle would take place in a context where Indigenous participants were engaged in a In recognizing the international right to self-determination and self-government, Mr. Chartrand referenced the constitutional structures of Canada and their implications. He noted that what works in the United States cannot be assumed to work in Canada. Care is needed in dealing with federal, provincial and municipal levels of government. He stressed the importance of understanding the distinctions between: citizenship rights; entitlements for every Canadian; and, Aboriginal and treaty rights. He suggested that federal and provincial governments should enter into agreements with First Nations to develop strategies and plans. He reminded Gathering Wisdom Forum participants that if they had an interest in changing the world, they had the capacity to do so. Further, he encouraged them to take care when making assumptions about who were First Nations gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

25 21 friends in health. A positive approach is essential when planning and taking on important initiatives that touch people s lives. To succeed, it is important to first determine the intended objective and then consider the feasibility of an action plan. The closing address from Mr. Chartrand involved the suggestion that some attributes of effective government include legitimacy and power. He suggested that legitimacy can be confirmed by considering what government and First Nations control systems were doing, and whether they have the support and confidence of people. In terms of power, it will be recognized both internally and by others. REGIONAL CAUCUS DISCUSSIONS Participants were invited to group into their respective regional groupings and concurrently discuss the Tripartite First Nations Health Plan governance process. Each region examined the specific questions of How do we apply what we have heard from the Health Governance Expert Panel and the Tripartite Health Governance Process into our work and region?. The discussions were led by a representative from each region who sits on the First Nations Interim Health Governance Committee. These representatives brought the issues discussed by their regions forward in a subsequent plenary. Key issues became apparent such as funding and regional diversity, the need for respectful communication, and the importance of asking questions. A summary of the plenary is provided below. Warner Adam, Northern Regional Member, First Nations Interim Health Governance Committee an issue; and that reaching an agreement-inprinciple by December 2009 was not feasible. He read from a position paper entitled Northern Chiefs Meeting on Health Governance, October 19 and 20, 2009, Northern BC First Nations Issues, First Nations Interim Health Governance Committee Northern Region. The paper contained a list of principles to be followed to ensure transparency with the Government of Canada. The principles referenced historical and systemic oppression and assimilation of First Nations; the violation of human rights experienced as a result of the inadequate level of services provided to First Nations; cultural insensitivity; upholding of the formal apology of the Government of Canada to First Nations for Indian Residential Schools; the effects of colonization; the urgency of federal and provincial financial resources; holistic definition of health and wellbeing; access to health for First Nations regardless of residency; social determinants of health; poverty; fair and equitable representation on pre and post structures dealing with health governance; diversity of First Nations; communication; maintenance of fiduciary obligations owed to First Nations by federal government. Mr. Adam s reported that the Northern Region participants suggest that a more reasonable pace be taken to reach an agreement-inprinciple. He added that outstanding issues such as the building of infrastructure related to health needed to be examined. Further, that a careful focus needs to be paid to improving Non-Insured Health Benefits. Importance was also placed on eliminating the status quo. A specific recommendation was that the cost of delivery and unforeseen impacts must be included in an escalator clause within federal and provincial agreements with First Nations. Warner Adam reported that the Northern Region participants had discussed the following: that the creation of a First Nations Health Authority was considered; that not all communities are up to date on the government s fiduciary obligations; that proper resources are v a n c o u v e r, british c o l u m b i a november 3-5, 2009

26 22 Gwen Phillips, Interior Regional Member, First Nations Interim Health Governance Committee Gwen Phillips indicated that the Interior Region group discussed the importance of understanding the mandate given to First Nations, and of moving forward at a comfortable pace. In general, it was hoped that First Nations would not oppose the process, and would look for answers to their questions. The Interior recognized that First Nations tended to work within boundaries, which needed to be re-considered as some First Nations are caught between health boundaries.the Interior reported a lack of services in many areas, especially in mental health, and acknowledged that the future operational costs need to be considered. The participants made a general suggestion for health service delivery involving the sharing of health specialists within the region. A connection between the political and technical levels was supported. Phillips reported that a gathering for the Interior was recommended, at which all Chiefs would get together. Further, an opportunity to support the work of health directors, and those with expertise on the ground, was necessary. Ms. Philips relayed the suggestion that a step-bystep road map of the process, including its early stages, be provided to BC First Nations. Some participants expressed concern that the process was a done deal, and they didn t fully understand it. As such, Phillips reported that the Interior participants suggested that the process be reconsidered in the future. Before the foundation can proceed the new process needs to be built from the ground up, starting with a blue print. The Interior Region participants questioned whether there is room in the process to create the right structures to achieve the best business case; as well as how the new agreement could proceed in light of First Nations and Inuit Health cutbacks. A moratorium on cutbacks is needed in order for the negotiations to move forward. Concern that different numbers have been quoted sparked the suggestion that fulldisclosure is necessary and resources to support the early stage of participation are required. Suggestions to nurture the historic relationship between First Nations and government bodies were also made. The Interior participants expressed that everyone will benefit from standing together, while it is still important to represent the diversity of the parties involved. The Interior Region participants concluded acknowledging the need for First Nation participation in sanctioning a clear process and the need to view all the agreements to move the process forward with their confidence. Chief Maureen Chapman, Fraser Regional Member, First Nations Interim Health Governance Committee Chief Maureen Chapman reported that participants from the Fraser Region recognized an opportunity to discuss Health Canada s health plan, re-shape data and accountability, and monitor the health governance process. The group discussed timelines and that it is was important for communities to be meaningfully involved, heard and informed. Rushing into a decision that people were unsure about was clearly not desired. Therefore, the participants suggested that information needs to reach communities so that everyone is kept up to speed. Chief Chapman relayed that questions arose regarding how the health governance process was going to incorporate treatment centres in the regions. She added that collaboration through education, children and families could not be done in isolation. The participants agreed that the presentation on Alaska health governance was impressive. A recommendation was made to dedicate more time at future Gathering Wisdom Forums for presentations. Chief Chapman also relayed some concerns that arose out of the Fraser Region gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

27 23 participants discussion on how they could break the information down for someone who was wondering how to feed their kids. To fully appreciate the experts present a suggestion was made for greater efforts to be taken to ensure a conductive environment. Chief Bob Chamberlain, Vancouver Island Regional Member, First Nations Interim Health Governance Committee Interim Health Governance Committee, and from leadership to the community, were expressed. Chief Chamberlin relayed concerns about whether or not a new agreement was a redesign of what already exists. Participants wondered whether First Nations control would be independent of the federal and provincial government, or whether First Nations were waiting for an answer on decisions that were already made. In general, the health governance process was recognized as a good example of a more inclusive way to deliver health. Questions raised in various topic areas included: the transparency of dollars; opting out issues; off-reserve citizens; transfer of administrative responsibilities; and, union and collective bargaining agreements. Some participants further questioned the tripartite negotiations and whether predetermined decisions were built in. Chief Bob Chamberlain reported that the Vancouver Island Region s discussion included various issues: federal offloading; the inequality of travel dollars for accessing services; the pace of development; input into the structure; and, political communication. Questions regarding getting concerns from leadership to First Nations As such, the issue of communications was a major concern for Vancouver Island participants. As discussed a regional voice is important. Given that there are a number of independent First Nations not a part of the BC Assembly of First Nations, First Nations Summit or the Union of BC Indian Chiefs, the inclusiveness of all 203 BC First Nations is important and necessary. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

28 24 Charles Nelson, Vancouver Coastal Regional Member, First Nations Interim Health Governance Committee BC CHIEF S UPDATE ON H1N1 Dr. Evan Adams/ Dr. Shannon Waters Co-Chairs, BC First Nations H1N1 Working Group Charles Nelson reported that the Vancouver Coastal group agreed that it was up to First Nations to come together, although support was needed to implement communications and staffing. In general, efforts to take the word interim out of the process are needed. Nelson indicated that it was important to address issues such as patient travel, capacity building and assistance to on and off reserve First Nations. It is necessary to determine what First Nations want and bring their concerns to the forefront. The participants from the Vancouver Coastal Region expressed that technicians required political support and feedback from the community. Participants further agreed that it was important to be able to transfer information to the new First Nations Health Authority. Participants do not want to create another bureaucratic system. In general, the group determined that a holistic focus on First Nations health is required. It is important for First Nations to work together to share information. However, in proceeding towards an agreement-in-principle, participants expressed concern that the fast-approaching December 2009 deadline was out of First Nations control. Presentation: H1N1 and First Nations in BC Dr. Adams and Dr. Waters reviewed the objectives of the H1N1 Working Group, which include: to decrease the impact of H1N1 on the health of First Nations in BC; increase reaction times and coordination efforts; provide information to support local community planning; and, commit to surveillance, characterization of the outbreak, vaccination programs, and timely care of people. They also noted the BC First Nations Working Group membership as including representation from: Health Authorities (Medical Health Officers, Aboriginal Health Leads); First Nations Health Council; First Nations & Inuit Health; Ministry of Healthy Living & Sport; and, the Public Health Agency of Canada. Dr. Evans and Dr. Waters discussed the commitment to collaborate with appropriate partners and stakeholders in the development, testing, and regular updating of a Community Influenza Pandemic Plan. They also indicated that the community-level plan should be incorporated into already existing emergency response plans. Efforts are also being made to ensure collaboration with federal and provincial governments, and regional health authorities, so gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

29 25 that all the elements of the Community Influenza Pandemic Plan are complementary. This will facilitate the execution of the community plan during an influenza pandemic. Dr. Evans and Dr. Waters assured that communities would be regularly updated, and be kept informed of the pandemic influenza situation. The presentation noted that everyone in BC was dealing with H1N1. One of the first things looked at was the unique situation of remote communities. An action plan was put in place for communities to be able to prepare and deal with H1N1. Dr. Adams and Dr. Waters described the pre-positioning of antivirals and personal protective equipment as an achievement - currently 50 communities now have antivirals in their community or nearby. Another achievement was point of care testing, to avoid lab test result delays, allowing health care providers to have information regarding whether patients may have H1N1. In terms of information for communities, the Tripartite Working Group is compiling communications products. Five tripartite communications have been released to date, the latest regarded communities and the vaccine. Dr. Adams and Dr. Waters discussed that efforts have been made to help influence where vaccines were given as priority. The focus of the vaccination program rolled out during the prior week was noted: those with chronic medical conditions under the age of sixty-five; at-risk pregnant women in the second half of their pregnancy; those in remote and isolated communities; First Nations citizens; children aged six-months to five years and their caregivers; and, healthcare workers. GWIII participants learnt that the Office of the Provincial Health Officer estimated that thus far 90% of First Nations in four of the five health authorities had access to H1N1 services. In conclusion, Dr. Adams and Dr. Waters recommended the vaccine as the best way for individuals and communities to protect their families. They also extended thanks to Dr. Alan Kendal for being influential in assisting with the action plan; to Dr. Perry Kendal for being a strong advocate; to medical health officers for being willing to listen to suggestions of the First Nations Health Council; and others. Q & A: H1N1 The question and answer period revealed several issues involving H1N1 and the BC First Nations population. Dr. Evan Adams reported that deaths are low in First Nations communities. He also indicated that immunizations were provided to First Nations. In terms of vaccination, the efforts to provide them are being rolled out with the province. All programs for First Nations immunizations are integrated so that First Nations people onreserve access vaccinations equally as other BC residents. Dr. Adams suggested that if an individual was concerned about receiving more vaccine, they could go through the respective regional health authority, or discuss it with the First Nations Inuit Health Branch of Health Canada. Dr. Adams provided himself as a contact if any more support was needed to receive the vaccine. He explained that shortages of the H1N1 vaccine were anticipated, as were shortages of nurses to administrate the vaccine. However, people in First Nations with flu-like symptoms can call in for a telephone diagnosis. The doctor can call in a prescription to the pharmacy for Tamiflu; a shot that should be taken within 24 hours of the onset of flu-like symptoms. Dr. Evans explained that Tamiflu is an anti-viral medication given to patients with H1N1 to prevent the onset of secondary infection such as pneumonia. For further assistance, Dr. Adams suggested that calling 811 was another option because of its 24 hours a day, 7 days a week accessibility. Further, First Nations and Inuit Health have a small group of nurses that can give vaccinations in communities that require additional help. For more information on vaccination and why it is important, Dr. Adams encouraged participants to peruse the Flu-watchBC website, and read H1N1 memos posted on Health Canada and First Nations Health Council websites. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

30 26 Feedback Form: November 3rd, Gathering Wisdom III - Health Governance The focus of discussions for Tuesday November 3rd, 2009 was Health Governance, the work to advance and create a new BC First Nations health governance model which is led by the First Nations Interim Health Governance Committee (FNIHGC). The FNIHGC was formed in 2008 at the direction of BC First Nations at the Second Annual Gathering Wisdom Forum. The FNIHGC hosted regional sessions to inform BC First Nations of the health governance within the TCA: FNHP and the TFNHP, and to seek information, support, advice and direction from all BC First Nations about the formation of a new health governance model. As a result of these sessions, the FNIHGC formed Regional Caucus in recognizing that BC First Nations are faced with unique health issues and concerns throughout BC. The methods used to analyze the data for this report used both qualitative and quantitative data from the Feedback Form: November 3rd, 2009 Gathering Wisdom III Health Governance which was collected from participants at the conclusion of the day. The report examines the total registered participants for all three dates, registered participants for each date, and of those registered participants that provided feedback at the conclusion of each session. The qualitative data collected and analyzed, was done so according to common themes that emerged in the feedback forms. The participation of BC First Nations and the Tripartite Partners over the course of three days was people attended Day 1 and 161 completed an evaluation form. The survey respondents were asked a total of eight questions. More specifically, questions seven and eight asked the participants to scale their opinions from poor, fair, average, good to excellent based upon the topic s discussed at GW III and to evaluate the forum on this date overall. Topics: Keynote address from Tripartite partners Health Governance Expert Panel Health Governance Plenary Regional Caucus Discussions North Health Authority Interior Health Authority Fraser Health Authority Vancouver Coastal Health Authority Vancouver Island Health Authority Update on H1N1 52% found this to be Good 44% indicated this to be Good 42% indicated this to be Good 25% indicated this to be Good 25% indicated this to be Good 20% indicated this to be Good 22% indicated this to be Good 23% indicated this to be Good 23% indicated this to be Good Overall Forum Evaluation: Design and content Aim, objectives/outcomes were clear Facilitators were well prepared Facilitators were knowledgeable Sessions were interesting Hotel accommodations Lunches and tea breaks 50% indicated this to be Good 46% indicated this to be Good 47% indicated this to be Good 44% indicated this to be good 48% indicated this to be Good 55% indicated this to be Excellent 40% indicated this to be Excellent The participants provided other general feedback and expressed that they enjoyed the conference and meeting staff. The speakers were found to be informative and the information at the booth useful. The participants expressed that the following should be the focus of discussions: consultation; finances of entities, budgets of federal and provincial governments and First Nations Health Council; dental, medical transportation, health benefits and funding issues; agreement-in-principle; health as wellness ; and representation. Recommendations included: providing more time for question and answer periods; distributing copies of presentations and providing biographies on speakers; hiring a consulting company with experience building health systems from the ground up in order to get all First Nations up to speed and for future planning; and that health directors should be involved and directing the political people to achieving goals and meeting First Nations people s needs and expectations. There is a need for clarification on representation and that the First Nations Health Council and First Nations Health Society represent all First Nations; and that youth should have more of a voice. Though the food was reportedly healthy it would be beneficial for more First Nations food groups to be provided. gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

31 % Update on Interim First Nations Health Governance Committee 54% Provide feedback to First Nations Health Council and/or their tripartite partners 52% Network with other community health professionals 9% Other 1. What were two key expectations for attending Gathering Wisdom Health Governance Day? Update on Interim First Nations Health Governance Committee (82%) Provide feedback to First Nations Health Council and/or their tripartite partners (54 %) Network with other community health professionals (52%), and Other (9%), please specify Nine percent of the participants that answered question one expressed miscellaneous other key expectations to include: opportunity to improve communication on behalf of communities; to bring general and health governance information back to their communities; to provide input into the health governance process ie. speak about traditional practices; to view Alaska and Maori presentations; to receive information on H1N1; to hear about what effect tripartite agreements may have on treaty negotiations; talk about community plans; and, to find out about Worker s Compensation Board Coverage for First Nations. Almost all of my needs have been met Most of my needs have been met Only a few of my needs have been met v a n c o u v e r, british c o l u m b i a november 3-5, 2009

32 28 Most respondents indicated that their expectations and most of their needs were met. A total of 13% of attendees indicated that almost all of their needs were met, a total of 50% indicated that most of their needs were met, and 32% indicated that only a few of their needs were met. 5% Other 50% Most of my needs have been met 13% Almost all of my needs have been met 32% Only a few of my needs have been met 3. Did the session(s) provide you with information or tools that were useful? No, definitely not No, not really Yes, generally Yes, definitely 0.69% indicated that they were not provided with the information or tools that were useful, while 16% indicated that they were not really provided with the information or tools that were useful. In contrast to this, it was shown that 66% indicated that they were generally provided with the information or tools that were useful, while 17% indicated that they were definitely provided with the necessary information or tools that were useful..69% No, definitely not.31% Other 16% No, not really 17% Yes, definitely 66% Yes, generally Participants that responded Yes, were then requested to provide further information about what it was that they found to be useful. The following types of information were found to be useful to the survey participants: Information and reporting on progress, commitments and process directly from people involved discussing agreements Visiting and dialogue Positive Attitudes and willingness to work together PowerPoint presentations Booklets Traditional Aspect prayer, drumming, respect for First Nations Clarifications on background information and plans Governance Process, Models, Framework & Best Practices Explanations and clarifications of processes Re-enforcement of temporary status and agreement is not a done deal Acknowledgment of barriers Expert Panel New Zealand and Alaska experience and perspectives Emphasis on good governance Discussion of timelines Discussion of fair representation and consultation gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

33 29 Regional Caucus Ability to network in meetings with regional representatives Regional Caucus activity updates Discuss health in local community Tripartite Agreements, Partners, Process Basic review of overall plan Commitment from Ministers H1N1 information 4. What were two things that you have learned from the Gathering Wisdom Health Governance day? The survey participants were requested to provide information on subject area s that they learned more about in the Health Governance discussions. A total of 35% survey participants provided qualitative feedback. In the following areas, the participants indicated that they learned more information and gained tools: 77% Communications/Background 35% Health & Wellness 5% Funding 98% Governance Process 40% Models of Governance 9% Governance Timelines 5% H1N1 4% Gathering Wisdom Forums % Communications / Background 35% Health & Wellness 5% Funding 98% Governance Process 40% Models of Governance 9% Governance Timelines 5% H1N1 4% Gathering Wisdom Forums 5. What is one thing that you liked best about the session(s)? Participants who responded to question five indicated miscellaneous aspects that they enjoyed about the session(s) including: Tripartite partners opening remarks Updates Health Governance Expert Panel sharing of governance models Questions and comments from the floor Breakout Sessions Discussions on health needs, governance and strategies for change Ability to share information and express issues within regions and with other regions Receptiveness to community voices and concept of community-driven governance structure Networking Opportunity for Self-Determination Relaxed atmosphere The number in attendance Nutrition and meals v a n c o u v e r, british c o l u m b i a november 3-5, 2009

34 30 6. If I could change one thing about the session(s), it would be? The participants that answered question six provided several types of suggestions as to what could be changed to improve future Gathering Wisdom Forums, which included the following: Better communication PowerPoints were difficult to see More discussion: drafts and papers involved in negotiations sports and recreation to improve health updates on timeline and process links to other social determinants ie. education, social welfare, poverty More information: Tripartite Agreement s effect on treaty negotiations - services More opportunity: meetings with all Regions at once ensure proper representation of communities question periods with Ministers questions and answers sessions More time: for individual regional discussions - no rushing of sessions More content: Add Elders content/ consider Elder Panel for guidance, support and encouragement Incorporate Cafe style discussions allow everyone to speak Less repetition: of older material Less talk and more action Improve atmosphere: more space bigger discussion rooms brighter lights more seating regulate heating in room 7. How would you rate the following? Topics Topics Poor Fair Average Good Excellent Participant Registration Keynote Address from the Tripartite Partners Health Governance Expert Panel Tripartite Health Governance Process Health Governance Plenary Regional Caucus Discussion: North Health Authority Interior Health Authority Fraser Health Authority Vancouver Coastal Authority Vancouver Island Authority Update on H1N gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

35 31 Overall Forum Evaluation Poor Fair Average Good Excellent Participant Registration Design and Content Aim, and objectives/outcomes were clear Facilitator(s) were well prepared Facilitator(s) were knowledgeable Session(s) were interesting Hotel accommodations Lunches and tea breaks Please feel free to give us any other feedback. The participants provided other general feedback about Gathering Wisdom III. In general, the participants expressed that they enjoyed the conference and meeting First Nations Health Council staff. Particularly, the participants found the speakers and information handed out at booths was useful, although suggested that more time could have been spent in question and answer periods. Further, copies of the presentations and biographies of speakers could have been distributed. In addition, individual evaluations of each speaker could have been collected. In terms of content of discussions, the participants expressed that the following content should be focused on more: consultation; finances of entities, budgets of federal and provincial governments and First Nations Health Council; dental, medical transport, health benefits and funding issues; agreement-in-principle; health as wellness ; and, representation. Participants generally enjoyed moving out of the mindset of dependency and towards the adopting or reclaiming of First Nations powers the concept of First Nations being responsible and accountable to First Nations In order to move forward. However, participants recommended that a consulting company could be hired, with experience building health systems from the ground up, to get all First Nations up to speed and planning the future. Further, that health directors should be involved and directing the political people to achieve the goals and meet needs and expectations of First Nations communities. There was need for clarification that representation on the First Nations Health Council and First Nations Society will represent all First Nations communities. There was also an expression that youth and should have more of a voice. The surveys used to collect information from participants of the Forum were appreciated by participants. In addition, the participants enjoyed draws for prizes. The food was expressed as healthy, but that more First Nations food groups would be beneficial. The temperature of the conference room was cold and could have been regulated better. Finally, the hand sanitizing stations were expressed as a good example of promoting the pandemic plan and safe hand washing. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

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37 DAY TWO: HEALTH ACTIONS Update on the Transformative Change Accord & Tripartite First Nations Health Plan Wednesday, November 4, 2009 Elder Virginia Peters from Chehalis First Nation welcomed participants to Day Two of the Gathering Wisdom Forum with an opening prayer.

38 34 ADDRESS BY FIRST NATIONS HEALTH COUNCIL Chief Lydia Hwitsum/ Debbie Abbott Co-Chairs, First Nations Health Council Presentation: Gathering Wisdom for a Shared Journey III. Lydia Hwitsum and Debbie Abbott jointly reviewed the presentation providing an update on the activities and evolving role of the First Nations Health Council, and introducing the First Nations Health Society s roles, functions and mandate. Chief Hwitsum opened the presentation by way of illustration. She recounted that in 2004 the Summit Chiefs in Assembly, concerned about the health of their communities, directed a contingent of Chiefs to open discussions with First Nations Inuit Health. At the time, there were limited opportunities to influence how health delivery priorities were set in the BC, look at how far we have come. How do we create amongst ourselves an influential voice to be involved as indigenous people, to set priorities based on the priorities of First Nations people and do the best with the budgets that we can and leverage resources? - Chief Lydia Hwitsum The Transformative Change Accord states First Nations will establish a First Nations Health Council. The Council will report to the First Nations Leadership Council, and will be composed of the First Nations Chiefs Health Committee, the Union of BC Indian Chiefs Social Development Committee and others. The First Nations Health Council was created through resolution of the Union of BC Indian Chiefs, First Nations Summit and BC Assembly of First Nations in Chief Hwitsum and Co-Chair Abbott reviewed the importance of determining a voice amongst the First Nations Summit, the Union of BC Indian Chiefs, and the BC Assembly of First Nations; and to finding ways to influence delivery and set priorities within the budgets available. They explained that efforts were needed to align resources of the three organizations, in terms of health services and policies, with multiple program pieces and strategies. The First Nations Health Council s focus is on: supporting all First Nations in achieving their health priorities, objectives and initiatives; participating in federal and provincial government health policy and program planning and processes; and, providing leadership in the implementation of the plan. A good example of the First Nation Health Council s leadership role was the H1N1 situation. A tripartite model was created with two Indigenous doctors as leads, specifically in response to H1N1 in First Nations communities. It was noted that the First Nations Interim Health Governance Committee led the governance work on behalf of the First Nations Health Council. Efforts are being made to focus on an administrative model that affects frontline delivery people and political representatives. First Nations Community Engagement Hubs create innovative, exciting and challenging opportunities; and test some unique health service delivery options. The First Nations Summit served as an interim administrative body for the First Nations Health gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

39 35 Council from its inception until An independent conduit was needed through which resources of the First Nations Health Council could flow for management and transparency purposes. Community Engagement Hubs create opportunities which are innovative, exciting and challenging and provide insight to community members on receiving, developing and supporting services to a community. - Debbie Abbott Subsequently in 2009 the First Nations Health Society was established to meet the requirements of the Transformative Change Accord Health Plan and the Tripartite Health Plan to: improve the ability to work effectively with all First Nations and to provide technical expertise and experience. The First Nations Health Society would: oversee the Society s business; develop and approve a strategic plan for the Society; approve annual action plans, operating and capital budgets; address risk management, organization and management capacity; and deal with hiring issues, including setting the terms of engagement for and overseeing the Chief Executive Officer. It has been a challenge to leverage a strong First Nations voice while respecting the political organizations mandates. Attracting people with a cross section of needed skills and experience was considered during the selection process of the First Nations Health Society Board of Directors. Board members need to reflect political advocacy and report to First Nations political organizations; and noted that the Society would likely sunset through the transformative change. Co-Chairs Hwitsum and Abott concluded that this initiative was the first of its kind in BC and in Canada and would impact generations to come. Reflecting indigenous world views, improving accessibility and prioritizing budgets are important change that will impact community health services. Q & A: Address by First Nations Health Council Participants discussed several issues regarding the challenging issue of representation, particularly for Northern communities. A concern raised was that not every community is represented by the three political organizations of the Union of BC Indians Chiefs, First Nations Summit and BC Assembly of First Nations. Solutions involved creating opportunity for communication and consultation and the development of a health plan for each community. To ensure that all 203 First Nations develop health plans participants learnt that staff will assist within the regions, and that a coordinator would be located in the North. An issue raised was the difference between jurisdiction and an administrative transfer. Participants were informed that in building a governance structure for BC First Nations health, several pieces needed to be considered. In the area of health, First Nations need to build capacity and have more influence over a process that affects their lives each day. Participants were assured that Aboriginal rights and title were not being tampered with; rather an administrative transfer was on the table. Participants questioned the function of the Social Development Committee whose mandate is health and links the social development, housing and education committees. Prior to each of the quarterly meetings technical support meet. Social issues are never interpreted as just one (ie. Special needs children) in the effort to break down silos. Suggestions included the need to engage other councils to discuss holistic approaches, break down silos, and influence positive outcomes for the future. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

40 36 ADDRESS BY TRIPARTITE PARTNERS Yousuf Ali, Regional Director, First Nations Inuit Health, Health Canada, BC Region Mr. Ali noted that as the third Gathering Wisdom Forum the event had grown in importance and attendance. He extended congratulations to the First Nations Health Council and the organizing committee for a job well done. While interest grew annually, the questions did not get any easier. The Forum is an opportunity to gather and share experiences and ask questions; it is also a time to find answers. I strongly believe that we have an opportunity for First Nations in BC to take control of their health and the commitment by the federal government has never been stronger; the voice you have at the cabinet table, never louder. - Yousuf Ali Yousuf Ali expressed his honour to be working in First Nations health for the past twenty-five years. He shared that in his work he has been warmly welcomed by First Nations. He reflected that he s witnessed many improvements in First Nations health. Green and yellow trailers were once standard health centres in First Nations communities; yet today there are over 100 new health facilities in First Nations communities. Recently, a health centre opened in Little Shuswap, and he noted that more were likely to come. He suggested that First Nations achieved these results by taking responsibility and control of health. The Regional Director reiterated that the process was about First Nations health by First Nations. He stated that First Nations communities have grown over the twenty-five years that he has spent working in First Nations health. Currently, there are over 200 nurses, many of which are First Nations, working in First Nations communities. He added that achievements were reached by Health Canada and First Nations working together as partnerships create strength. He expressed his belief in the opportunity for BC First Nations to take control of their health; as the federal government s commitment has never been stronger and the First Nations voice at the cabinet table has never been louder. He added that there is a greater understanding of the daily challenges faced by First Nations. Concerns have been raised and it is now time for efforts to be made to improve services and get new services within First Nations communities. He commented that Leadership s expectation of perfection is unfair. Efforts should be made to work towards providing input, advice and guidance to enable the creation of solutions and decisions to improve BC First Nations health. Regional Director Ali noted that First Nations guidance has shaped many initiatives within First Nations communities already; and that working towards the health of First Nations people in each community is a key consideration. A concern was raised regarding communities who currently have knowledge and expertise; and whether these communities were continuously seeking better services. He confirmed that not one of the 203 First Nations, 65,000 people living on-reserve, or the same gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

41 37 number living off-reserve, would be left behind as efforts move toward improving the health of all BC First Nations. Andrew Hazelwood, Assistant Deputy Minister, Ministry of Healthy Living and Sport Regional Director Ali concluded by extending his thanks to the First Nations Health Council for bringing people together for the Gathering Wisdom Forum. He relayed his appreciation to the nurses in the communities for their tireless work during the H1N1 pandemic. He wished participants a successful Forum, and encouraged conversation focused on how to close the gaps between the health of First Nations and other British Columbians. Andrew Hazelwood explained that the Tripartite First Nations Health Plan was the first of its kind in Canada. In terms of its goal of closing the gap between First Nations people and other British Columbians, progress has been made in He noted that childhood vision, hearing and dental screening in First Nations children had been a priority. He also noted the achievement in the cooperative arrangement between the governments of Canada, BC and First Nations and the health authorities in BC. These relationships, he stressed, were essential for achieving the objectives of the Tripartite First Nations Health Plan. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

42 38 Mr. Hazelwood reported that changes have already impacted health outcomes of First Nations people in BC, and that First Nations cultures and context had been reflected, in the areas of prevention and mental health. Further, he indicated that partnerships had been evident in the H1N1 pandemic when provincial and federal agencies, in partnership with First Nations worked together to respond to the pandemic. He noted it would not have been possible to respond, in such short time, if relationships and processes had not already been in place due to the tripartite plan. Joe Gallagher, CEO, First Nations Health Council The creation of a First Nations Health Authority will open up opportunities for better linkages for services and with provincial health authorities. - Yousuf Ali The governance aspects of the plan have been difficult, Hazelwood commented. The governance agreement lays the groundwork for First Nations to assume a greater role in First Nations health. He noted this was the case especially as it related to creating better linkages with provincial health authorities. Hazelwood referenced that the H1N1 Working Group had been meeting weekly to support First Nations communities and respond to their needs. Hazelwood reported on a number of activities including: training delivered to increase capacity within First Nations and to improve the birthing experiences of Aboriginal women; dental and hearing screening offered to all First Nations children in BC; and, the Mental Health and Substance Use Plan had been developed. He added that the Tripartite Suicide Forum Working Group was working towards planning a youth forum. Another achievement noted, was the June 2009 release of the Provincial Health Officer s Report, Pathways to Health and Healing, which provided some understanding of current First Nations health status. In closing Mr. Hazelwood noted that more work is to be done in terms of understanding roles and responsibilities of all parties. Relationships are very complex especially in terms of finding a way to move the Plan forward so everyone feels part of it; has meaningful role and is involved in a process which has value. Joe Gallagher acknowledged participants for their interest in the gathering, He recognized that the relationships arising out of the Tripartite First Nations Health Plan were complex, yet finding a way to move forward critical. He indicated that he would discuss how the tripartite partners were working together, the questions asked by First Nations to date, and the First Nations Health Council s role. Gallagher reviewed how the Transformative Change Accord (TCA) was reached in Kelowna in 2005, and was signed by the First Nations Leadership Council, the Premier and Prime Minister. The TCA called for ten year plans in health, education, housing infrastructure and economic development. He noted that the Health Plan could achieve some things in the TCA, while the other commitments were being addressed through other initiatives. The First Nations Health Council focuses on where progress can be made in health and in the gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

43 39 Transformative Change Accord. There are areas where good progress can be made, and Mr. Gallagher stressed the importance of focusing on a wellness perspective within First Nations philosophies rather than focusing on a sickness system (ie. Measuring illness). Mr Gallagher spoke of the value of Community Engagement Hubs. The Hubs were created to assist health directors who stated that they could not implement the Health Plans off the side of their desks. The Hubs could also enable resources to be dedicated to planning, provide opportunities to work with all communities, and ensure adequate communications at all levels. Currently there are 150 communities organized around 24 Hubs. Further, community liaison positions are being established in a few regions to reach out to communities in areas that are not part of a Hub. Included in the Tripartite Health Plan process is the partnerships with health authorities. For example on Vancouver Island the health authority is co-hosting a Community Development Liaison position. The five regional caucus discussions that occurred on Day One of the Gathering Wisdom Forum were referenced. Mr. Gallagher added that efforts were needed to take direction from the regions on how best to support the caucuses. For example, opportunities are needed for several coordinators to work in the regions on health governance, which are important under the Tripartite Health Plan. In addition, Mr. Gallagher commented that the Community Health Plans covered a range of services provided by the federal government; however, the provincial government also has responsibilities towards First Nations citizens. He noted that as the service plans for health authorities may not hit the mark in some cases, and as a result detailed discussions are needed. A community-driven and wellness focused perspective is required to move health planning forward. As efforts move forward it is important not to forget the health actions as they must move along with health governance. On this note, he added that a legislative framework is required to provide the new arrangement with power and authority (i.e. better opportunities to influence monies spent). Mr. Gallagher acknowledged that it is important to provide leadership on behalf of the three political organizations, Union of BC Indian Chiefs, First Nations Summit and BC Assembly of First Nations. He placed importance on the task of reporting to the organizations and regional engagement. These efforts are needed to take the federal and provincial components of the health system and have them managed through a First Nations lens. An effective First Nations health organization still needs to be developed. Accordingly a lot of work has gone on to support the governance level. In an accelerated timeframe, he noted that it is crucial to find a way to maintain good traction on some areas that were already moving forward. To do so government relationships are necessary. As a result it is important to understand the federal bureaucracy in order to learn how to interface with it. On the issue of connectivity, Mr. Gallagher noted that it is essential that effective TeleHealth opportunities are made available. These need to be linked into decision makers, and done so that First Nations systems are communicating well with the relevant health authorities. A Tripartite First Nations e-health strategy council could help make decisions to ensure the larger plan accommodates ground level needs. In closing he noted that there would be discussions regarding different activities in First Nations health. Referencing a quote from a book by Rupert Ross, written on a blackboard in a First Nations community, that said I believe you understand what you think I said, but I m not sure you realize that what you heard is not what I meant. He encouraged the use of clear words and careful listening in the afternoon discussions with the health authorities in order to move health actions forward. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

44 40 Q & A: Address by Tripartite Partners Elder Pierre John spoke about what he was taught as a young man, If you want a good life, and to be a good man, be kind to everybody, smile when you meet people and say hello. Treat people nicely, including your neighbours and everybody will love you. That is what I do in my life. Elder John s concern was that Northern people felt left out, and in his comments he encouraged working together with love, prayers, unity, respect and forgiveness. LUNCH SPEAKER Zhila Kashaninia, PHO Office, Managing Editor of Pathways to Health and Healing Elder John s wisdom, teachings and comments were heard, and it was stated that a greater understanding of how to get along and support one another was crucial in discussions about BC First Nations health; an area that encompasses the life and death of BC First Nations people. Presentation: Pathways to Health and Healing Zhila Kashaninia provided a review of the Province of BC s 2 nd Report on the Health and Wellbeing of Aboriginal People in British Columbia that was released in June 25, The report tracked and reflected changes in Aboriginal health conditions with the 1st report in 2001; provided a report on the status of 2001 recommendations; and set out new recommendations. gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

45 41 Ms. Kashaninia reported that the study found that rates were worsening in the following areas: children in care; preterm births; low birth weight; TB incidences off-reserve; HIV/AIDS; housing; and the use of prescription drugs. She displayed charts indicating instances and rates within the First Nations population related to the following: life expectancy at birth; deaths from all causes; motor vehicle accidents; drug induced deaths; accidental poisonings; suicides; alcohol-related deaths; medically treatable diseases; HIV; Medical Services Plan utilization; births by adequacy of care; pregnancies preterm birth rates; low birth weights; infant mortality; total youth suicides; suicide rates by number of factors present; average daily rates of youth in custody; and graduation rates. Ms. Kashaninia noted that the study concluded that it was critical to: commit to making self-determination in the province a reality; examine and review systemic barriers to economic development and make them a priority; continue to improve the socioeconomic status by creating more educational and job opportunities; focus on implementing demonstrated best practices so that children can fully benefit from educational opportunities; improve housing and the physical environment; work on Aboriginal health plans for health authorities; recommit to achieving stated goals; make issues underlying HIV/AIDS a priority; and, create a provincial Aboriginal mental heath and wellness plan. HEALTH EXPERTS PANEL Linda Kay Peters, Seabird Island Hub Anne Cochran, Nlaka pamux Services Society Hub, Fraser Health Region Presentation: Community Hubs, Turtle Island A turtle shell is a mosaic of uniquely patterned squares much like the mosaic of communities in a HUB Linda Kay Peters and Anne Cochran jointly reported that the early days of Community Hubs focused on collaboration, planning and communications. Generally communities took tentative steps forward within each Hub, taking turns in leading efforts to share services, planning, information, resources, and make collective decisions on common and independent initiatives. Peters and Cochran indicated how Hubs have formed new partnerships. The Nlaka pamux Hub. located at the south and north ends of the Fraser Canyon, includes the communities of Spuzzum, Boothroyd, Boston Bar, and Oregon Jack Creek. The Seabird Island Hub, located in the Fraser Valley Region, includes the communities of Chawathil, Shxw ow hamel, Union Bar, Cheam, Scowlitz, Seabird, Chehalis, Skwah, Kwaw Kwaw Apilt, Kwantlen and Soowahlie. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

46 42 In reviewing achievements of the Fraser Region community hubs the presenters noted that the Nlaka pamux Hub hosted ongoing meetings with Chiefs, Band Mangers and the health team, and established community mental wellness plans for their communities. The Seabird Hub had hosted a Hub gathering, began community consultation sessions, established a Hub Committee, held a Hub Committee Strategic Planning Session, and developed a communication plan and promotional materials. In closing, the presenters expressed hope that the Community Engagement Hubs, and collaboration among Hubs would continue to grow. Manuhuia Barcham, PhD, Synexe Consulting Ltd., Palmerston North, New Zealand Presentation: Thinking about Indigenous Health Service Models It s important to not only talk about leaders, but what about those who are led? Leadership is there to bring together a coalition of people to do something. Mr. Barcham discussed the population comparisons between New Zealand, Australia, Canada and the United States. He recognized that almost one in every five New Zealand people self-identified as Indigenous. He noted a similarity between New Zealand and BC s First Nations people was that both had lower life expectancy rates than the general population. Mr. Barcham provided historical background information relative to Indigenous rights in New Zealand, recognizing the similarities between the push by BC First Nations for greater involvement in decision making, and the push for Aboriginal Medical Services in the 1970s in New Zealand. Following these initial efforts the first Maori Health Provider was established in the early 1990s. Mr. Barcham discussed that Maori people do not typically access the health services available, as they were not designed for Maori people. He described a situation where an elderly male Maori with diabetes was treated at the hospital in the same way as a non-aboriginal and as a result left before being treated. This situation resulted in the Maori persons eventually suffering renal failure, a more costly care option that had to be dealt with later. He added that focusing on wellness promoted healthy First Nations populations. Traditionally the Maori people were mobile and moved to where food was, making it difficult to track them. In the modern health system for Maori, Mr. Barcham noted that key priorities included the implementation of a region wide population based approach to healthy lifestyles. The program contains three key components including a community program, social marketing strategy and structural intervention. The program focuses on several health initiatives: intervention around nutrition - including breastfeeding; and, exercise and reduction of tobacco use in order to reduce diabetic, cardiovascular and carcinogenic risk among Maori, Pacific Islander people and others living in high deprivation areas. Mr. Barcham noted that many of the social and health initiatives have been led by women. He also referenced the Central Australian Aboriginal Congress: Male Health Initiative. In general, male Indigenous health involves issues such as violence against women and sexual abuse etc. gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

47 43 The Central Australian Aboriginal Congress: Male Health Initiative in particular, tried to switch this around and shift towards strengths-based programs, while building on tradition. For example, young men that go through traditional initiation processes are encouraged to use clean instruments for his initiation into manhood at each stage to prevent blood born diseases. Mr. Barcham closed by suggesting that the positive outcomes in health for Maori people have allowed them to remain strong in their culture. He also encouraged participants to build on the successes of others. Valerie Davidson, Senior Director Alaska Native Tribal Health Consortium where the average village population was 350 people. Ms. Davidson reviewed infrastructure within the Alaska Tribal Health System. Throughout Alaska, there are 180 small community primary care centres, 25 sub-regional mid-level care centres, four multi-physician health centres, and six regional hospitals. She explained that additional funding is available if an individual needs to go outside the system for complex care. Further, there are physicians and specialty providers assigned to certain communities that are expected to travel four weeks out of the year. The 180 small village primary care centres offer community heath aides and practitioners, behavioural health aides, dental health aides/ therapists, and home health/personal care attendants. The 25 sub-regional mid-level care centres are located in Hub communities and provide surrounding small villages with mid-level providers; modest radiology and lab services; dental operatories; and, behavioural health professionals. Presentation: Alaska Tribal Health System: Introduction and Lessons Learned. We want our children to be happy and to live in safe communities but because of where we live, our Tribal status, our issues of sovereignty and health status, we may have to do things differently to make that possible. Valerie Davidson explained a key principle for First Nations people was to get health care as close to home as possible. As such, she noted that approximately 55% of patient encounters in Alaska were now occurring at the village level, Ms. Davidson also discussed the Alaska Native Medical Centre in Anchorage that provides primary hospital services for Alaska Natives from Anchorage, and rural south Alaska. The hospital also serves as tertiary and specialty care for all regions, offering 150 beds, 250 medical staff, over 700 nursing staff and a $250 million operating budget. The wellness system concept was stressed by Ms. Davidson, rather than a sickness system. She indicated that the Alaska Native Tribal Health Consortium built sanitation facilities, as infants in communities without adequate sanitation are significantly more likely to be hospitalized for respiratory or skin infections. Ms. Davidson expressed the importance of transparency, especially during negotiations. Everyone knows how much money each tribe receives, which helps build trust. Financial resources are also available for primary care, hospital and clinic funds, targeted funds, contract health services, as well as contract v a n c o u v e r, british c o l u m b i a november 3-5, 2009

48 44 support costs that pay for any patient travel (with an escort), legal costs, rent, overhead costs etc. In terms of funding, the Indian Health Service did not historically fund behavioural health services. There was an initial focus on primary care, with the intent to focus on long term care as the system evolves. Ms. Davidson acknowledged the stigma about mental health, and noted that a decision was made to incorporate behavioural health service with primary care services. She noted that facilities funds were kept separate from health service funding. Over 100 Alaska health facilities had been replaced, according to Davidson. Requests for funding are not limited to the Indian Health Service. Ms. Davidson stressed the importance of determining early on what to settle for, what to negotiate for and what not to. She encouraged participants that it was beneficial to negotiate as sovereign nations. If the federal government made resources available for a national health program, the same services need to be made available for First Nations communities. In the take over of programs, Davidson encouraged participants to think of themselves as a health provider. Further, if community health centres were providing health in rural locations, more funding should be sought from the government. First Nations citizens are tribal members, citizens of BC, and citizens of Canada. As a result it is critical to remember that they are eligible for anything non-first Nations citizens are eligible for. She reminded participants that Alaskan native families want what every American family wants to be happy, healthy and live in safe communities. However, because of their tribal status, Alaskan natives must do things differently. Davidson concluded that when young Native Alaskan citizens talk about their future, they demonstrate a clear understanding that they do not have to settle. She encouraged participants to: design a new health authority; to identify what health experiences no one in the First Nations communities should ever have to experience and focus on fixing those; to further identify some of the best health experiences and make sure they are available to everyone. First Nations citizens are tribal members, citizens of BC, and citizens of Canada. As a result it is critical to remember that they are eligible for anything non-first Nations citizens are eligible for. gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

49 45 HEALTH ACTIONS UPDATES Participants were invited to attend one of five separate discussions focussed on the following topics: Mental Wellness and Substance Misuse; e-health and Data; Primary Health Maternal and Child Health; and Cultural Competency. The discussions were guided by the following focus questions : How do we work collectively? How do we coordinate our services and programs regionally? Cultural Competency: Leslie Varley, Director of Aboriginal Health, Provincial Health Services Authority Cross-cultural training was seen by participants as necessary to work towards better understanding in areas such as: nursing care; temporary health professionals within a community; understanding of systems and cultural protocols; and, diagnosis of medical conditions in First Nations patients. As part of a solution, it was suggested that training be done in schools; that bridges of understanding be built for health professionals to be integrated into the culture; that training be provided directly within communities, that more Aboriginal physicians and nurses be trained, that knowledge of the balance between western and traditional medicine be shared, and that better communication be instituted with hospitals dealing with Aboriginal patients. Mental Wellness & Substance Misuse: Jean Albeury, Prevention and Wellness Coordinator, First Nations Health Council Carole Patrick, Regional Consultant, Mental Health & Addictions Programs and Strategies, First Nations and Inuit Health Tara Nault, Acting Director, Strategic Initiatives, Aboriginal Healthy Living Branch, Ministry of Healthy Living and Sport Presentation: Update on Mental Health and Substance Use The presenters provided an overview of comments received during the Health Directors Forum and Tripartite Engagement process and a summary of tripartite activities and accomplishments. First Nations and Inuit Health, Health Canada s BC region oversees 14 National Native Alcohol and Drug Addiction Program treatment centres. The centres are located in communities and the Directors must be certified to receive a salary increase. Programs for development and certification of addiction workers were reviewed. The presenters encouraged participants to contact the First Nations Health Council for further information related to funding available to certify workers in individual communities. The presenters reviewed the kinds of things being looked at in response to the needs of First Nations (ie. Suicide prevention and treatment programming). It is necessary to understand the root causes such as sexual abuse and violence; and Indian Residential School counselling does not have a limit like crisis mental health counselling does. Recommendations were made including: more treatment centres; support for people with Fetal Alcohol Syndrome; resource development; support for wellness within communities; accommodation of diverse cultural backgrounds; more counsellors within communities; support v a n c o u v e r, british c o l u m b i a november 3-5, 2009

50 46 for sports and recreation (i.e. KidSport in Hazelton area & North American Indigenous Games; and youth camps); support for people leaving treatment; longevity of programs and funding; and, the development of an emotional health curriculum in the Ministry of Education in BC. E-health & Data: Gavin Eaton, ehealth Director, First Nations Health Council An update was provided on First Nations e-health via a video presentation providing technical information on client heath records and electronic health records system. Further, a review of the e-health action items as discussed at Gathering Wisdom II, tripartite activities and accomplishments was provided. Next steps were identified including the use and development of: community engagement including a Core First Nation e-health Advisory; Panorama Implementation Working Group; Strategic planning and current state assessment; Connectivity Engagement Working Group; and, the Centre of Excellence Capacity and Distribution e-health Leadership. In addition, a questionnaire was distributed to receive feedback on the views of Health Directors at the Forum on a number of issues. There were 30 participants that responded to the questionnaire, and the results are summarized below. The Health Directors in attendance indicated that they are primarily focused on management of health policy and services. The top challenges that Health Directors face in rolling out e-health include: connectivity; sustainability; insufficient e-health funding; capacity and resources; and, lack of collaboration. The top information and services that health directors required from the Centre of Excellence included: support to build infrastructure; implementation support; educational services; integration of information; data sharing agreements; community training; and health reporting. The methods of communication that were seen as best for communities included: electronic (i.e. website and ); paper; community visits; and, through designated resources from the Centre of Excellence Capacity and Distribution e-health Leadership. The importance of e-health in the communities was rated strongly agreed/agreed 88% of the questionnaire participants. The key e-health developments to date included: establishment of the Tripartite Strategy Council for First Nations e-health; the Technical Working Group for First Nations e-health; the First Nations ehealth Centre of Excellence; Connectivity advancements through the Pathways to Technology Project and Connectivity Steering Committee; and, the establishment of the Centre of Excellence Capacity and Distribution e-health Leadership. Primary Health: Georgia Kyba, First Nations Health Council Suzanne Johnson, First Nations Health Council Pamela Morrison, First Nations & Inuit Health Matt Herman, Ministry of Healthy Living and Sport Michelle DeGroot, First Nations Health Council Denise Lecoy, Ministry of Healthy Living and Sport Presentation: Primary Health Gathering Wisdom Day 2 A series of other presenters accompanied Georgia Kyba including: Suzanne Johnson who reviewed tripartite activities and accomplishments in primary health on behalf of the First Nations Health Council; Pamela Morrison who discussed disease prevention for First Nations and Inuit Health; Matt Herman who reviewed activities and accomplishments in injury prevention on behalf of the Ministry of Healthy Living & Sport; Michelle Degroot who reviewed activities and accomplishments in gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

51 47 health promotion for the First Nations Health Council; and, Denise Lecoy who addressed health promotion with a focus on the Honour Your Health Challenge program and the Sun Run Training Program on behalf of the Ministry of Health Living and Sport. Participants suggested that a report should be prepared on the chronic disease management work to inform best practices. They were assured that the First Nations Health Council is working on developing best practices for chronic disease management with a target date of January In terms of sports and recreation, participants questioned what funding was available for schools and communities. The concern was that obesity was prevailing in many First Nations due to lack of activity among community members and action needed to be taken. The First Nations Health Council acknowledged the issue, noted that it has provided some successful initiatives to promote sports and recreation in First Nations; and indicated that consideration should be given to including it as part of an action item within the health plan. The participants also questioned whether the Community Diabetes Foot Care and Prevention Program were to receive funding in additional areas beyond what is being funded now. They were provided a number of contacts through which communities could ascertain what is available in or near their respective communities. Maternal & Child Health: Michelle Warr, First Nations and Inuit Health Christine Atkins, BC Association of Aboriginal Friendship Centres Carla Springinotic, Ministry of Healthy Living and Sport Lucy Barney, Public Health Services Authority Presentation: Maternal Child Health Gathering Wisdom for a Shared Journey III Several challenges accessing health and dental care were described by participants such as: on-reserve capacity; educational opportunities for health providers and doulas (midwifes); resistance to policies and billing system such as dentists who are unwilling to work with the difficulties of receiving payments from status Indians; transportation; high turn-over rate of health staff; lack of incentives for patients to access services; and inadequate prevention and promotion services. In general, the participants were concerned about First Nations children that were not able to access health and dental services that they are eligible for; and the competition created each fiscal year between all 203 First Nations for funding for Maternal and Child health programs. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

52 48 Feedback Form: November 4th, 2009 Gathering Wisdom III Health Actions The focus of discussions for Wednesday November 4th, 2009 was Health Actions, the work to identify and close the gaps in health and well-being between BC First Nations and other British Columbians. The Transformative Change Accord: First Nations Health Plan (TCA: FNHP) identifies 29 actions as priorities and is intended to guide efforts to address challenges and deliver joint efforts to improve the health and well-being of BC First Nations. The Tripartite First Nations Health Plan (TFNHP) is an agreement the partners to explore, develop, test, and implement new health priorities, structures and processes. Most important, the TFNHP recognizes local health plans for BC First Nations are needed and recognizes community solutions and approaches to identify and close the health gaps. The methods used to analyze the data for this report used both qualitative and quantitative data from the Feedback Form: November 4th, 2009 Gathering Wisdom III Health Actions which was collected from participants at the conclusion of the day. The report examines the total registered participants for all three dates, registered participants for each date, and of those registered participants that provided feedback at the conclusion of each session. The qualitative data collected and analyzed, was done so according to common themes that emerged in the feedback forms. The participation of BC First Nations and the Tripartite Partners over the course of three days was 984, of that 397 were registered to attend on this date and of that there were 120 participants that completed an evaluation form. The survey respondents were asked a total of eight questions. More specifically, questions seven and eight asked the participants to scale their opinions from poor, fair, average, good to excellent based upon the topic s discussed at GW III and to evaluate the forum on this date overall. Topics: Tripartite Opening Remarks Health Expert Panel Health Actions Update Mental Wellness & Substance Misuse Ehealth & Data Primary Health Maternal & Child Health Cultural Competency Regional Discussions North Health Authority Interior Health Authority Fraser Health Authority Vancouver Coastal Health Authority Vancouver Island Health Authority 65% indicated this was Fair 48% indicated this was Good 23% indicated this was Good 18% indicated this was Good 16% indicated this was Good 87% indicated this was good 23% indicated this was Good 18% indicated this was Good 12% indicated this was Good 4% indicated this was Good 7% indicated this was Good 7% indicated this was Good Overall Forum Evaluation: Design and content Aim, objectives/outcomes were clear Facilitators were well prepared Facilitators were knowledgeable Sessions were interesting Hotel accommodations Lunches and tea breaks 52% indicated this to be Good 37.5% indicated this to be Good 43% indicated this to be Good 46% indicated this to be good 43% indicated this to be Good 44% indicated this to be Excellent 42.5% indicated this to be Excellent The participants provided other general feedback and expressed that they enjoyed the conference and meeting staff. The participants especially enjoyed the opportunity to share information, network, and express common issues and concerns with other First Nations. Participants especially expressed delight with the Elder who spoke about traditions, more grass-roots approaches on working on behalf of all First Nations people. Recommendations included: more time for question and answer periods; distribute copies of presentations and biographies of speakers; and better quality sound equipment to be available in all sessions and presentation to allow for improved participation. The participants expressed that they would like to attend all Health Action break out sessions in accordance with the TCA: FNHP and the TFNHP, this could be accomplished by adding another date to the forum so that the participants can be updated on all health actions. Further, participants are seeking more clarity about the structure and the roles and responsibilities of the First Nations Health Council, the First Nations Health Society, and the Board of Directors. First Nation community member want to know who the staff gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

53 49 are so that they know who to contact for assisting with organization, structure, and messaging to the partners with the use of current data. 1. What were two key expectations for attending Gathering Wisdom Health Actions Day? Update on the TCA and Tripartite FNHP Health Actions Provide feedback on the TCA and Tripartite FNHP Health Actions To network with other community health professionals Other, please specify The overall two key expectations for attendees on November 4th, 2009 Gathering Wisdom III Health Actions day were: Update on the TCA and Tripartite FNHP Health Actions To network with other community health professionals For the eight percent of survey participants that indicated Other in their response, their key expectations were: to be provided with an updated progress report to update their communities as some felt their communities were not actively involved in the process, the process was moving forward with little to no consultation with First Nation community involvement, and to bring forward their community concerns; information gathering for progress and involvement with Health Action groups and other organizations; and to become familiar with the First Nations Health Council, key players, structure and purpose. 2. To what extent has the Gathering Wisdom Health Actions day met those expectations? Almost all of my needs have been met Most of my needs have been met Only a few of my needs have been met 2 % Other 17 % Indicated almost all of their needs were met 28% Indicated only a few of their needs were met 53% Indicated most of their needs were met Most of the participants indicated that their expectations and most of their needs were met. As shown in the chart/graph above, 17% indicated almost all of their needs were met, a total of 53% indicated that most of their needs were met, and 28% indicated only a few of their needs were met. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

54 50 3. Did the session(s) provide you with information or tools that were useful? No, definitely not 3% No, not really 13% Yes, generally 72% Yes, definitely 25% No, definitely not % No, not really % Yes, generally % Yes, definitely A majority of the participants indicated that the information and tools gathered were generally useful, while 25% indicated the information and tools gathered were definitely useful. On the other hand, 3% indicated the information and tools provided were definitely not useful in comparison to 13% who indicated the information and tools were not really useful. Participants that responded Yes, were then requested to provide further information about what it was that they found to be useful. The following is information that was found to be useful to the survey participants: Health Actions: Updates, Progress, Need For More Community Assessments, Planning & Coordination of Health Plans, Collaboration, Need For More Primary Health, FNHC is Assisting Communities With Planning, Gained Knowledge About Various Programs and Services and To Access Resources for Implementation, Information Gathering For Community Planning and Direction, Vaious Key Players at Multiple Levels, Common Gaps Identified, Communications: Presenters, Sessions, Panel, Media, Agenda, Information Sharing with other First Nations, Lack of Communications and Need for Consultation, Information Tables, Service Delivery Models, First Nations Need and Want to Engage Provincial & Federal Partners, and To Take Place with Community Members As Well As Leadership and Health Directors Transformative Change Accord: First Nation Health Plan & Tripartite First Nation Health Plan: Service Delivery Models, Process, Highlights of Progress for Past Year, Next Steps, Planning, Slow Process, Need and Desire for More Comprehension of the Plans and Process, Collaboration, Gaps Are Being Reduced But Still Higher Than The General Population, Action Items Will Vary for Communities and Regions, Status Highlighted for Past 3 Years and Successes To Date E-Health: Planning and Implementation Community Requests: Infrastructure, Planning, Resources, Programming and Services Governance Model: Planning and Implementation Regional Health Authority: Key Players, Alignment of RHA Plans with the TCA: FNHP & TFNHP gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

55 51 4. What were two things that you have learned from the Gathering Wisdom Health Actions day? The survey participants were requested to provide feedback pertaining to what they thought were two things that they learned from the Gathering Wisdom Health Actions sessions. Information on subject area s that they felt they learned more about, and survey participants provided qualitative feedback on what they found to be useful on this date. These are the area s that participants learned more information and gained tools: Communications: Presenters, Sessions, Panel, Media, Agenda, Information Sharing with other First Nations, Lack of Communications and Need for Consultation, Information Tables, Service Delivery Models, More Regional Perspectives, Northern Communities Feel Disconnected, Community Engagement, Updates, Grass Roots Communication is Lacking, Understand the Process Transformative Change Accord: First Nation Health Plan & Tripartite First Nation Health Plan: Service Delivery Models, Process, Progress, Next Steps, Planning, Updates, Needs Assessment, Community Health Plans, Work Collectively, Health Gaps Are Reducing But Still More Change Needed, Primary Health, Concensus Building, Stronger Concepts, FNHC Assistance for First Nations Communities to Develop Health Plans Aligned with TCA: FNHP & TFNHP, Regional Health Issues, Benefit for Communities, New Ideas, Access to Service & Programs, Past, Present & Future, Key Players Identified, Existing Programs & Services, Health Gaps Identified, Explanation of First Nation Health Society Board of Directors, Explanation of First Nations Health Council, Year In Review, FNHC Specific Initiatives, 3 Year Progress Report, Need More Understanding, Process Proceeding Without Community Consultation/Involvement, More Research, Framework is Essential, FNHS Staff, Collaboration Governance Model: Planning and Implementation, Comparison with Other Indigenous Models of Health Care Delivery Health Actions: NNADP, Cultural Competency, Research and Data, First Nations Centre of Excellency, Capacity Building, Maternal & Child Health, Drug & Alcohol, Resource availability, Request for Child Welfare program, Action Plan for all First Nations, Request for Sports programs, Request for more meetings, More Northern Representation, Community Engagement, E-Health, Mental Health & Substance, Cultural Enhancement, Request for more Youth & Elder Involvement, FNIHB Funding Formula, RHA & FNIHB Need More Collaboration, Support Services, Change Process is Challenging, Resources Are Needed to Implement Plans, Accountability, Suicide Youth Prevention, Aboriginal Diabetes Initiative, Chronic Disease Management, Update, Home & Community Care, Community Struggles, Historical Issues are Relevant Presently 5. What is one thing that you liked best about the session(s)? The survey participants were requested to provide feedback pertaining to what they liked best about the sessions while in attendance at the Gathering Wisdom Health Actions day: Tripartite Opening Remark by Joe Gallagher Health Expert Panel Health Action Updates Regional Discussions Elder Speech Information Sharing Meeting the Minister Networking Assertion of Rights Communications More Clarity on the First Nations Health Society and the First Nations Health Council Question and Answer Self Care Stations Technical Equipment Governance Models of Other Indigenous people Community Engagement Hub Presentations v a n c o u v e r, british c o l u m b i a november 3-5, 2009

56 52 6. If I could change one thing about the session(s), it would be? The survey participants were requested to provide feedback pertaining to what they would change about the sessions: More participants Representation from all Regions Health Promotion in Sports and Recreation More Question and Answer Sessions Biographies and Handouts of Presentations & Speakers An additional day for Gathering Wisdom Forum Contact Details of presenters, staff, participants Improve the Process Organization of Speakers and Presentations Facilitation in Sessions (need for more and organization) and Microphones More First Nation Health Council Updates More Time for Input Limit Speakers on Floor Registration for Sessions Too much information to review Invite Elders & Youth gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

57 53 7. How would you rate the following? a) Topics Topics Poor Fair Average Good Excellent # Surveyed Total Reg Tripartite Opening Remarks Health Expert Panel Health Action Updates: Mental Wellness & Substance Misuse Ehealth & Data Primary Health Maternal & Child Health Cultural Competency Regional Discussion: Northern Health Authority Interior Health Authority Fraser Health Authority Vancouver Coastal Health Authority Vancouver Island Health Authority b) Overall Forum Evaluation Poor Fair Average Good Excellent # Surveyed Total Reg Design and content Aim, and objectives/outcomes were clear Facilitators were well prepared Facilitators were knowledgeable Sessions were interesting Hotel accommodations Lunches and tea breaks v a n c o u v e r, british c o l u m b i a november 3-5, 2009

58 54 8. Please feel free to give us any other feedback. In general, the participants expressed that they enjoyed the forum, discussions, and sessions. More specifically, the participants expressed there was a rush in the presentations, sessions, discussions and not enough time to engage with the presenters, question and answer, and there is a need for a quality sound system in each room and this would assist in participants being able to interact with materials being presented and presenters. Also, participants expressed the agenda was too packed and suggested perhaps an additional day for Health Actions, and so that participants could attend multiple health action sessions, regional discussions, and ensure each session match the health actions in the TCA: FNHP and the TFNHP. This opportunity would allow for a bigger picture understanding of the health action outline in the TCA: FNHP and TFHP, the past, present and future. The participants especially enjoyed the opportunity to share information, network, and express common issues and concerns with other First Nations. Participants especially enjoyed the speech from an Elder who spoke about traditions, more grass-roots approaches on working on behalf of all First Nations people. It was requested that there be more Elder involvement into the process as well as youth involvement. Further, participants are seeking more clarity about the structure and the roles and responsibilities of the First Nations Health Council, the First Nations Health Society, and the Board of Directors. First Nation community member want to know who the staff are so that they know who to contact for assisting with organization, structure, messaging to the partners with the use of current data to advocate for improved programs and services. Further, participants requested additional information to become available about the Community Engagement Hubs and Health Directors Associations so that people understand who they are, their purpose, and how they are to assist in the process. Participants would like to see documents available on the FNHC website, to ensure all decision making documents, agreement, etc are accessible to all. Participants also expressed their concern for the lack of Northern representation in decision making governing bodies and this is an issue that needs to be addressed. gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

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61 day THREE: Health directors Health Directors Association and Professional Development november 5, 2009 Participants were greeted on Day Three of the Gathering Wisdom Forum with an Opening Prayer offered by Elder Barbara Charlie from the Squamish Nation.

62 58 HEALTH MANAGER NATIONAL ASSOCIATION Health Directors from BC First Nations have been meeting for years to discuss opportunities to meet the needs of their communities. There has been consistent support raised for a BC First Nations Health Directors Association. The development of this Association is identified as one of four governing components in the Tripartite First Nations Health Plan. Laurette Bloomquist, Health Director, Tla amin Community Health Services Ella Arcand, Tribal Chiefs Ventures Inc. First Nations Health Mangers Association Presentation: First Nations Health Manager National Association Advisory Committee (FNHMAC) Laurette Bloomquist and Ella Arcand provided an overview of efforts to develop a national First Nations Health Managers Association. They indicated that in their view BC was ahead of other provinces in rolling out their own Health Directors Association, and that the work being done nationally was parallel to the work being done regionally. The Association was recognized as an opportunity to identify how to address concerns, provide tools to Health Directors, increase awareness of their challenges, and develop skills ad knowledge to influence healthy outcomes for First Nations community members. The presentation explained that the First Nations Health Manager National Association Advisory Committee was mandated by the Assembly of First Nations and the First Nations and Inuit Health Branch to provide leadership, partnership and advice on: the development of a national set of First Nations Health Managers Competencies that communities may wish to adopt; the identification of effective First Nations Health Managers recruitment and retention strategies; the development of a communication framework; the establishment of a national network of First Nations Health Managers; and, the development of an informative website and e-portal for First Nations Health Managers. Various achievements of the First Nations Health Manager National Association Advisory Committee to date were listed, including: the commissioning of the 2008/2009 National Aboriginal Health Organization (NAHO) situational analysis and needs assessment; completion of a literature review of other competency frameworks; sponsorship of two First Nations Health Managers National Forums; completion of the First Nations Health Managers gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

63 59 Competency Framework; and, establishment of the National Association Working Group. The presenters reviewed the purpose of the First Nations Health Manager National Association which is to: provide First Nations Health Managers with a voice on health matters; provide professional support; build credibility; promote knowledge sharing; offer training, professional development and certification; increase networking; and, apply a cultural lens to heath matters. The Association s goals are to: improve skills and capacity in community health services; professional development; networking and support; increase the ability to attract and retain health workers; and, development to meet community health needs. The importance of data collection was referenced by Laurette Bloomquist and Ella Arcand. The example given was that unless data is collected correctly, it may never be known how many First Nations people have passed away from H1N1 complications. Findings of the Situational Analysis and Needs Assessment were presented and it was noted that cultural awareness arose as a main requirement for a Health Director. General consensus was that essential skills for a Health Director included communications, accountability, fiscal and human resource management, connection to community, understanding the communities culture and values, understanding of the co-relation between First Nations history and current the its health status (i.e. Residential schools and colonization). The recommendations arising out of the Situational Analysis were reviewed. They included a call to: support the development of standards, ethical guidelines and best practices similar to a professional association; create mentorship and job exchange process; develop a certification process for Health Directors using developed curriculum and modules; and, create a Health Director s network to support and share information. They reported on communications efforts being made with regions, provinces and territories regarding the work of the First Nations Health Manager National Association Advisory Committee, and how they can be linked to the regional level. Participants were informed that a regional session could be held with BC Health Directors in early March 2010 in Kamloops. Bloomquist and Arcand noted that although initial funding for the First Nations Health Manager National Association was from the Treasury Board, efforts are needed to enable them to become self-sustaining. v a n c o u v e r, british c o l u m b i a november 3-5, 2009

64 60 FIRST NATIONS HEALTH DIRECTORS ASSOCIATION Review of Health Directors Survey Results: Laura Jameson, Health Director, Little Shuswap Aileen Prince, Health Director, Nak azdli First Nations Health Directors Association September of 2008 to discuss the structure and functions a BC First Nations Health Directors Association. At this forum, the participants entrusted a sub-committee of Health Directors to develop a model structure for the Association. The sub-committee compiled a list of recommendations for the Association s model structure based on the Health Directors Summary Report of September The recommended structure, in the form of a survey, was circulated and posted on the First Nations Health Council s website for input from BC First Nations Health Directors in all five health regions in BC. The presenters expressed the subcommittee s hope that the model structure would be adopted at this gathering. A copy of the survey booklets, Health Directors Survey Report was distributed for further details. During the presentation a number of recommendations were reviewed. These recommendations generally called for: capacity development; strong communication links between communities and the Association; support for Canadian health legislation; a northern administration office; and, equitable services at the community level. The survey results contained Health Director feedback on the components of the Association including its purposes, membership, voting rights, annual membership fees, and a regional structure along the lines of the five health authority regions. Jameson and Prince concluded by informing participants that the BC First Nations Health Directors Association is ready to move forward and that it will set a good standard for other provinces to follow. Laura Jameson and Aileen Price expressed pleasure to be working towards formalizing an association to address shared issues that First Nations have identified over many years. The BC First Nations Health Directors held a Forum in gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan

65 61 Review of Proposed Association Model: Kim Brooks, Health Department Head, Squamish Nation directors of off-reserve organizations. Annual membership fees were proposed at one hundred dollars, with small bands eligible to apply for fee subsidies. The survey results indicated that full members would have the right to one vote. The survey also confirmed that full members can vote by proxy at annual or special general meetings, but that board members could not vote by proxy at board meetings. The survey indicated that Northern, Interior and Vancouver Island Regions will each have three board members, while the Fraser and Vancouver Coast Regions would each have two board members. The Board of Directors would appoint officers who would be reimbursed for expenses associated with performing their duties (i.e. wage recovery) based on levels to be set at an annual general meeting of the Association. Laurette Bloomquist, Health Director, Tla amin Community Health Services First Nations Health Directors Subcommittee Kim Brooks and Laurette Bloomquist elaborated on the survey results and how that translated into a proposed model for the BC First Nations Health Directors Association. They stressed that it will be critical for association to bring the Health Director s voice into the governance process within the Tripartite First Nations Health Plan, the governance of the association itself and the sharing of information, networking and knowledge. Brooks and Bloomquist reviewed the proposed structure of the Association and recommended that it be comprised of five regions: Vancouver Island, Vancouver Coastal, Interior, Fraser and the North. Two types of Association membership were discussed and it was recommended by the sub-committee that full membership be open to Health Directors or Managers responsible for health administration in the First Nation, Society or Tribal Council; and that associate membership would be open to retired directors, students or In concluding comments, the presenters reiterated that forming a non-profit society would provide a structure that would allow a voice for Health Directors to be included at the governance level within the Tripartite First Nations Health Plan. An association would further support how decisions are made with respect to the types of services delivered at the community level. Q & A: First Nations Health Directors Association Several issues arose based on the proposed model for the First Nations Health Directors Association in BC including: the purpose of the membership fee and how it was determined; representation; potential seats for Elders and Youth. Following the favourable vote on the association and at the inaugural meeting of the association s board of directors these issues could be further examined. The participants were informed that the proposed membership fee was based on the structure of other organizations, recognizing that some financial structure and backing are required. With approximately 200 members, the one hundred dollar membership fee would v a n c o u v e r, british c o l u m b i a november 3-5, 2009

66 62 contribute to a percentage of the Association s operational costs. Financial support would be further discussed with the First Nations Health Council and Health Canada. In the funding of the Association, there would be no infringement of anyone else s funding levels. In terms of representation, participants from the Interior indicated more Board representation would be required. However, it was explained that creating a Board of Directors that is workable can be challenging. The Board must make guiding decisions for the Association and be a manageable size. The sub-committee recommended thirteen board members to be a manageable size. In this structure, the whole province would be covered geographically. Through discussing the fundamental issues related to service and supply at annual general meetings, membership would guide the process. The membership would include associate members who can be youth, students, retired health directors and Elders expressing an interest in community health. This proposed model sets out the structure of the founding Board and enables the association to be formed. As health directors continue to come together they will determine what regions look like and who needs to be at the table. Nations acknowledged; and the importance of family and culture stressed. Rachel Andrew Nelson, the new Health Directors Coordinator at the First Nations Health Council introduced herself. Nelson has been involved in health since 1983, and prior to her position with the Health Council been a health director for approximately five years. Vote to Form First Nations Health Directors Association: 87% voted yes Andrew Benson, a consultant, assisted with the electronic voting process to determine whether or not to form the First Nations Health Directors Association in BC. He explained the electronic voting process and led the participants in a voting response to the question: I hereby vote for the formation of the First Nations Health Directors Association. Following the vote, Benson announced a total of 91 responses, of which 87% were in favour and 13% were opposed to the formation of the First Nations Health Directors Association. As they arise, challenges and gaps will be addressed; the linguistic diversity of BC First gathering wisdom for a shared journey a dialogue on the tripartite first nation health plan