DESCRIPTIVE OF PHASE II

QUEBEC FIRST NATIONS' HEALTH AND SOCIAL SERVICES GOVERNANCE PROCESS DESCRIPTIVE OF PHASE II REPORT PRODUCED BY

QUEBEC FIRST NATIONS HEALTH AND SOCIAL SERVICES GOVERNANCE PROCESS DESCRIPTIVE OF PHASE II

WRITING Emilie Grantham, FNQLHSSC COLLABORATION Patrice K. Lacasse, FNQLHSSC Suzie Nepton, FNQLHSSC Marjolaine Siouï, FNQLHSSC TRANSLATION Meaghan Girard GRAPHIC DESIGN Mireille Gagnon, FNQLHSSC Patricia Carignan This document is available in French and can be downloaded from the FNQLHSSC s website at www.cssspnql.com. Any reproduction, in whole or in part, is subject to prior authorization, which may be requested from the FNQLHSSC by mail or e-mail at: First Nations of Quebec and Labrador Health and Social Services Commission 250 Place Chef-Michel-Laveau, Suite 102 Wendake, Quebec G0A 4V0 info@cssspnql.com Photo credit: 123rf, Tapiskwan, FNQLHSSC, Shutterstock ISBN: 978-1-77315-029-1 Legal Deposit 2016 Bibliothèque et Archives nationales du Québec / Library and Archives Canada FNQLHSSC 2016

CONTENT 1 Context 1 2 Purpose and objectives of the process 2 3 Breakdown of process 3 4 Overview of phase I (2012-2016) 5 5 Phase II (2016-2020) 8 6 Conclusion 12

1 CONTEXT Quebec First Nations form a special group on a legal and jurisdictional level. Although they have rights to self-government, they are subject to both federal and provincial legislation. This political situation in turn makes it both complex and difficult to transition towards a significant and even urgent improvement for the health of the people. This reality, which is reflected in all spheres of activity, does not always allow First Nations to be the key builders of a society that matches their vision. The United Nations, the World Bank and many other experts in the field acknowledge that "evidence has correlated self-governance advancements with improved socio-economic conditions in Indigenous populations. As such, sound governance is fast becoming a prerequisite for rapid improvement in the well-being of communities and nations' citizens." 1 Agreements between the Government of Canada and the Government of Quebec seeking to give First Nations communities and organizations control over the range of health and social services they offer are essential and contribute to their greater well-being. The health and social services directors from the communities formalized their thoughts on the current mode of governance in the Blueprint: Quebec First Nations Health and Social Services 2007-2017. An entire chapter from the Blueprint, entitled "A renewed approach to governance fostering self-determination," 2 presents the current situation, identifies the challenges to overcome and provides focus areas and actions to that end. The Quebec First Nations' health and social services governance process therefore falls within this scope of activities and reflections, which have already been underway for several years now. POSITIONING FIRST NATIONS AT THE CENTRE OF DECISIONS FOR THEIR HEALTH AND SOCIAL SERVICES IS ESSENTIAL TO EFFECT LARGE-SCALE, SIGNIFICANT CHANGE. 1 Kaufmann, D. et al. (1999). Governance Matters. Available at www.worldbank.org 2 First Nations of Quebec and Labrador Health and Social Services Commission (2007). Blueprint: Quebec First Nations Health and Social Services 2007-2017. 1 DESCRIPTIVE OF PHASE II

2 PURPOSE AND OBJECTIVES OF THE PROCESS The goal of the Quebec First Nations' health and social services governance process is to improve the wellness of First Nations. This can be achieved by improving the supply and accessibility of local and regional health and social services, namely through the implementation of a governance model adapted to the needs and realities of First Nations. BY THE END OF THIS PROCESS, FIRST NATIONS WILL HAVE COLLECTIVELY BUILT AN ALTERNATIVE GOVER- NANCE MODEL AND WILL HAVE COMPLETED ALL THE NECESSARY PLANNING TO IMPLEMENT IT. To that end, the process proposes to put in place conditions to improve the self-determination of communities and organizations in terms of health and social services. Backed by a process of collaboration, consultation and analysis, First Nations will have all the necessary information to select their institutions and mode of governance in health and social services. The process' long-term objective rests on two medium-term objectives: To strengthen the decision-making capacity of communities and regional organizations with respect to health and social services governance in relation to existing health and social services, programs and initiatives. To strengthen partnerships with government institutions, in accordance with a governance model adapted to the needs and realities of First Nations. 2 QUEBEC FIRST NATIONS HEALTH AND SOCIAL SERVICES GOVERNANCE PROCESS

3 BREAKDOWN OF PROCESS In order to have all the necessary information in hand to develop a new governance model, it is essential to build the process on several activities coordinated by the First Nations of Quebec and Labrador Health and Social Services Commission (FNQLHSSC): A consultation and integration process involving all stakeholders A portrait of the environment, including a macroeconomic study and a portrait of the functions and responsibilities of Health Canada's First Nations and Inuit Health Branch (FNIHB) and Indigenous and Northern Affairs Canada (INAC) The development of regulation, intervention and political structures as well as mechanisms for stakeholder involvement that fall in line with the concept of effective governance A process to approve the newly developed model A feasibility study of the model, including impact and risk assessment analyses Talks with the federal and provincial governments to validate their intention of delegating powers to First Nations in terms of health and social services A negotiation process involving the federal and provincial governments to define the responsibilities of all parties A transition plan and several implementation scenarios A service offer transformation plan A communication plan This process excludes activities associated with land claims, the review of governance modes outside the purview of health and social services and the comprehensive implementation of the transition plan towards the new health and social services governance model. 3 DESCRIPTIVE OF PHASE II

PARTNERS In addition to First Nations communities and organizations, the process is able to move forward due to the collaboration of several partners. PARTNERS ROLES IN THE PROCESS Assembly of First Nations Quebec-Labrador (AFNQL) Ministère de la Santé et des Services sociaux du Québec (MSSS) Health Canada s First Nations and Inuit Heath Branch (FNIHB) Headquarters and Quebec Region office Indigenous and Northern Affairs Canada (INAC) Headquarters and regional office Secrétariat aux affaires autochtones (SAA) The member communities and organizations of the AFNQL, as well as their Chiefs and advisors, are regularly consulted and informed of the progress made on the file Three Chiefs are members of the Chiefs Advisory Committee Participate in the Committee of Partners Provide the necessary knowledge in terms of the organization of health services Inform and liaise with the Quebec health and social services network Keep MSSS authorities informed of the work of the Committee of Partners and the governance process Participate in the Committee of Partners Share information on its functions and responsibilities Keep Health Canada authorities informed of the work of the Committee of Partners and the governance process Participate in the Committee of Partners Share information on its functions and responsibilities Keep INAC authorities informed of the work of the Committee of Partners and the governance process Participate in the Committee of Partners Keep SAA authorities informed of the work of the Committee of Partners and the governance process 4 QUEBEC FIRST NATIONS HEALTH AND SOCIAL SERVICES GOVERNANCE PROCESS

COMMITTEES Two advisory committees were created during the first phase of the process in order to support the implementation of the process and assist the FNQLHSSC team with project coordination. Committee of Chiefs The Committee of Chiefs, which is composed of three Chiefs of the AFNQL, is mandated to advise the FNQLHSSC team on political considerations in order to respect the needs of communities. This committee issues strategic orientations and forwards the political concerns of all the AFNQL Chiefs. During the second phase, this committee will also be mandated to regularly report on the progress of this process to the Assembly of Chiefs. Committee of Partners Composed of representatives from INAC, the FNIHB, the SAA, the MSSS, the AFNQL and the FNQLHSSC, the Committee of Partners provides a platform for First Nations and government partners associated with the project. The objective is to mobilize all partners and keep them informed of the project and to ensure collaboration at all levels in order to make progress on this file. 4 OVERVIEW OF PHASE I (2012-2016) Health Canada's FNIHB began providing funding for the first phase of the project in 2012 through the Health Services Integration Fund (HSIF). Funding for an additional year was earmarked to the project through a commitment from Minister Aglukkaq. The FNQLHSSC was mandated by the AFNQL to coordinate this large-scale project at the regional level. Since 2013, representatives from communities and organizations have shared their opinions on the need to make significant changes to the current mode of governance, attesting to the direct link between the degree of self-determination and the wellness of their populations. 3 The first phase of the process was critical, as it provided stakeholders with sufficient time to understand the process and lay the foundations of the new model. 3 First Nations of Quebec and Labrador Health and Social Services Commission (2015). Summary Report Joint Meeting of the AFNQL-FNQLHSSC, January 27 and 28, 2015. 5 DESCRIPTIVE OF PHASE II

COLLECTIVE LEARNING During the first phase, it became apparent that the consultation process had to respect a certain pace in order to ensure collective learning and integrate knowledge on the concept of governance. The top-down approach historically adopted by governments is to be avoided, and First Nations have spoken out in favour of being an integral part of the development of the new governance model. During the entire first phase, there was a concern for the quality of the consultation process and the time allocated to collective reflection. The importance given to collective learning prevails over meeting strict deadlines and achieving results in the prescribed timeframe. The first phase, anchored as it was in the regional meetings that brought together decision-makers from the communities and organizations, made it possible to develop a shared understanding of the federal and provincial environment. Decision-makers had the opportunity to discuss the ways the current mode of governance in health and social services did not function as it should. 4 VISION, VALUES AND PRINCIPLES In February 2014, the Chiefs of the AFNQL adopted a vision statement during a special assembly. 5 This vision will guide the health and social services governance process: THROUGH OUR SELF-DETERMINATION, A GLOBAL AND CONCERTED APPROACH, INDIVIDUAL AND COLLECTIVE COMMITMENT, WE WILL BE HEALTHY PEOPLE CONNECTED TO MOTHER EARTH AND OUR PHYSICAL, MENTAL, EMOTIONAL AND SPIRITUAL WELL-BEING WILL BE BALANCED. This vision was completed with eight principles and six values. 6 Principles 1 We affirm that our ceremonies, values, languages, teachings and traditional medicines are an integral part of our way of living healthy life. 2 We affirm that the First Nations healing journey will be strengthened when considering the person and the environment as a whole. 3 We affirm that the social determinants of health to First Nations are unavoidable to address health issues. 4 We affirm our right to self-determination and our inherent right to have and to freely pursue our own health, economic, social and cultural development. 5 We affirm that the ten Nations are responsible for First Nations health. 4 First Nations of Quebec and Labrador Health and Social Services Commission (2015). Abstract of Health and Social Services Issues. 5 First Nations of Quebec and Labrador Health and Social Services Commission (2016). A Renewed Approach to Governance Fostering Self-Determination, 2 nd edition. 6 Ibid. 6 QUEBEC FIRST NATIONS HEALTH AND SOCIAL SERVICES GOVERNANCE PROCESS

6 We affirm that responsibilities of the local and regional institutions are to manage, protect and enhance health and social services programs according to the mandates they received from Nations and First Nations communities. 7 We affirm that our regional institution supports First Nations in their autonomy quest in supporting strategic alliance building between First Nations with governments in their organization of health care and services, development of expertise as well as knowledge transfer. 8 We affirm that the federal government has a legal and fiduciary duty and constitutional responsibility to provide adequate, sufficient and sustainable financial resources for the development, implementation, management and delivery of quality health programs and services that respond to our needs and taking into account the determinants of health. Values Honesty Respect Autonomy Community Solidarity Assistance EFFECTIVE GOVERNANCE The current mode of governance in health and social services is built on an approach of government and good governance, which in turn hinges on accounting practices and policies that are determined by non-first Nations authorities and yet apply to all communities and organizations. An effective governance approach will make it possible to achieve the collective goal of improving the wellness of First Nations, as per the needs expressed. Effective governance focuses on achieving results to evaluate all policies stemming from regulatory and intervention processes. To be effective, governance must involve all social actors Responsibility in the mode of governance and thus allow Politics for a better understanding of the goals to be reached. The first phase of the project led to the development of a framework model of effective governance. This framework model was the result of a stakeholder involvement mechanism, which was further backed by an analysis of the environment. Several documents 7 were produced, and these will continue to support the development of an alternative model of health and social services governance. Structure Regulation process Legitimate authority of the governance mode Collective objectives Improve First Nations wellness Mechanism to ensure everyone s involvement Stakeholders Involvement Improvement Intervention process Structure 7 The documentation can be consulted on the website of the Quebec First Nations health and social services governance process: http://www.cssspnql.com/en/areas-of-intervention/governance-project-on-health-and-social-services 7 DESCRIPTIVE OF PHASE II

5 PHASE II (2016-2020) The second phase of the process is dedicated to appropriating the framework model and developing different structures and rules of operation that will guide the transformation of health and social services governance practised by First Nations in Quebec. At the beginning of phase II, the AFNQL Chiefs, gathered in assembly, renewed their support of the process. The resolution adopted in April 2016 reiterates the mandate of the FNQLHSSC, and further mandates it to approach the federal and provincial governments and enter into talks to agree on a transition process towards a new governance model that gives First Nations more autonomy in terms of health and social services. EXPECTED RESULTS OF PHASE II The following results are expected by the end of phase II (March 2020): An effective health and social services governance model will be available and applicable. This model will respond to the needs expressed. Alternative models of governance will be presented to the Chiefs, together with the recommendations of the general directors, health and social services directors in the communities and representatives from other organizations, so that the Chiefs may adopt a position and orient the negotiation and transition phase. A feasibility study including the transition, transformation and change management plans will be developed so that all parties are informed of the impacts, the conditions for success and the risks associated with the adoption and implementation of the new model. The accountability requirements and jurisdiction in health and social services at the federal, provincial and First Nations levels will be clarified. The Committee of Partners will receive an expanded mandate for phase II. The members of the committee will focus on the grey zones surrounding federal and provincial jurisdictions. This committee will liaise between the political and administrative bodies and will provide an additional platform on which to discuss these issues and find sustainable solutions. The decision-makers will thus be in a position to develop and adopt a health and social services governance model that is adapted to the needs and context of First Nations, as well as put in place a permanent mechanism to resolve jurisdictional disputes. 8 QUEBEC FIRST NATIONS HEALTH AND SOCIAL SERVICES GOVERNANCE PROCESS

ONGOING ACTIVITIES Regional meetings Regional meetings will regularly be held throughout the second phase to bring together key stakeholders, thus providing a forum for all parties to discuss their realities and issue recommendations in order to build a model that addresses the needs and diversity of communities and organizations. Community visits The FNQLHSSC team will visit the communities and organizations upon request in order to answer their questions, discuss local needs and provide all the necessary information to pursue the reflection process surrounding the development of the new governance model. Advisory committees Throughout the second phase, regular meetings will be held with the Committee of Chiefs and the Committee of Partners in support of the FNQLHSSC's mandate to coordinate the process. Regular updates The FNQLHSSC provides updates on the progress made in the governance process whenever it attends meetings with various stakeholders (e.g. health directors network, Assembly of Chiefs, general directors network, childcare services network, income assistance advisors, regional round table). Communication plan The FNQLHSSC is always working to improve communication channels with partners. The communication plan sets out to mobilize and regularly disseminate information to all stakeholders. 2016-2017 ACTIVITIES Pre-AGA 2016 of the FNQLHSSC The key role of culture has been emphasized since the beginning of the process. The new governance model must be integrated into the existing culture of each community. During the FNQLHSSC s pre-annual general assembly on July 13, 2016, the general objective was to begin reflection on how to integrate the governance model into the culture of each nation. 8 8 First Nations of Quebec and Labrador Health and Social Services Commission (2016). Summary Report, Pre-Annual General Assembly, July 13, 2016. 9 DESCRIPTIVE OF PHASE II

Portrait of the functions and responsibilities of the FNIHB and INAC The objective of this portrait is to understand and integrate the functions and responsibilities of the FNIHB (headquarters and Quebec Region office) and INAC (headquarters and regional office) in order to determine the responsibilities that First Nations want to assume moving forward. To complete this portrait, the FNQLHSSC team met with teams from both organizations. These meetings will allow the FNQLHSSC to identify the authorities, responsibilities, functions, policies and obligations of these teams as well as the financial, material and human resources they have. Regional meeting, November 9 to 10, 2016 The fall 2016 regional meeting will provide a forum for the health and social services directors and general directors to continue their reflection regarding the integration of the new governance model into the culture of the communities. This meeting will also focus on developing collective knowledge on the current functions and responsibilities of the federal government. Regional meeting, winter 2017 Another regional meeting will be held in winter 2017 in order to build on the reflection undertaken in fall 2016. FORTHCOMING ACTIVITIES (UNTIL 2020) Tripartite agreement-in-principle A tripartite agreement-in-principle (federal, provincial, First Nations) will be developed and proposed in order to formalize the transition process. This formal process will facilitate information sharing and ensure the participation and collaboration of all parties, with a view to ensuring the transition towards the new health and social services governance model. Development of new structures For purposes of effective governance, which is the approach chosen to develop the new governance model, First Nations will have to reflect on the different structures and rules of operation to put in place at the local and regional levels. Regulation structure: Structure to determine and administer the policies, standards, programs and resource allocation mechanisms designed to achieve the collective objective of improving wellness. Intervention structure: Structure to ensure the deployment of programs and services in the communities and organizations. 10 QUEBEC FIRST NATIONS HEALTH AND SOCIAL SERVICES GOVERNANCE PROCESS

Stakeholder involvement mechanisms: Mechanisms to involve all stakeholders, which allow a better understanding of the project's goals. Political dimension: The implementation of the new governance model hinges on the agreement reached by the political authorities. This agreement will legitimize the governance model. In keeping with these structures and dimensions, the following questions will serve to guide further reflection: What bodies will need to be created to repatriate policy-making and regulatory powers from the FNIHB and INAC? What bodies should be created or modified to strengthen ties between the services offered by the communities and organizations and the regulatory bodies? What changes should be made to ensure that the best services are offered by First Nations communities and organizations? How can the various stakeholders be coordinated to improve the health and wellness of First Nations? What mobilization bodies should be created? What bodies will be able to legitimize the authorities that will be created or put in place? Feasibility study of the new model An impact and risk analysis regarding the repatriation of powers will be carried out. Chiefs adoption of the model The new health and social services governance model will be adopted in 2019 by resolution of the Chiefs of the AFNQL. Transition and change management plan In order to develop a transition plan towards the new model, consultations will be held among all stakeholders. 11 DESCRIPTIVE OF PHASE II

6 CONCLUSION The development of a new governance model by and for First Nations will pave the way for collective efforts to improve the wellness of First Nations in a way that respects local autonomy. By sharing knowledge and experiences, Quebec First Nations will build a governance model in their image that can be integrated into their cultures. Furthermore, this new model will empower First Nations to determine the services they wish to offer to their populations as well as the policies that will guide their institutions. They will also be able to promote a holistic approach that prioritizes and acts on the social determinants of health. 12 QUEBEC FIRST NATIONS HEALTH AND SOCIAL SERVICES GOVERNANCE PROCESS

A RENEWED APPROACH TO GOVERNANCE FOSTERING SELF-DETERMINATION The health and social services governance process is part of an effort aiming to develop the autonomy of First Nations. Communities have found that the current health and social services governance model does not meet the needs of the First Nations in Quebec. Therefore, the Chiefs of the Assembly of First Nations Quebec-Labrador entrusted the FNQLHSSC with the mandate to coordinate the development of a governance model that is adapted to the needs and context of the First Nations in Quebec while also being conducive to self-determination. This model is called the health and social services governance process. The process is guided by the vision that was adopted by the Chiefs of the AFNQL in 2014: Through our self-determination, a global and concerted approach, individual and collective commitment, we will be healthy people connected to Mother Earth and our physical, mental, emotional and spiritual well-being will be balanced. For more information, please visit the website at www.cssspnql.com/champsintervention/gouvernance. SUMMARY The first phase of the governance process was critical, as it provided stakeholders with sufficient time to understand the process and lay the foundations of the new model. The second phase of the process is dedicated to appropriating the framework model and developing different structures and rules of operation that will guide the transformation of health and social services governance practised by First Nations in Quebec.