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Health Promotion: An Effective Tool for Global Health

Sanjiv Kumar and GS Preetha

International Institute of Health Management Research, New Delhi, India

Address for correspondence: Prof. Sanjiv Kumar, Dean Training, Research and Publications, IIHMR, Plot No. 3, Sector 18A, Dwarka, New Delhi- 110 075, India. E-mail: moc.liamg@tixidramukvijnasrd

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Received 2012 Jan 14; Accepted 2012 Jan 14.

Copyright : © Indian Journal of Community Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract

Health promotion is very relevant today. There is a global acceptance that health and social wellbeing are determined by many factors outside the health system which include socioeconomic conditions, patterns of consumption associated with food and communication, demographic patterns, learning environments, family patterns, the cultural and social fabric of societies; sociopolitical and economic changes, including commercialization and trade and global environmental change. In such a situation, health issues can be effectively addressed by adopting a holistic approach by empowering individuals and communities to take action for their health, fostering leadership for public health, promoting intersectoral action to build healthy public policies in all sectors and creating sustainable health systems. Although, not a new concept, health promotion received an impetus following Alma Ata declaration. Recently it has evolved through a series of international conferences, with the first conference in Canada producing the famous Ottawa charter. Efforts at promoting health encompassing actions at individual and community levels, health system strengthening and multi sectoral partnership can be directed at specific health conditions. It should also include settings-based approach to promote health in specific settings such as schools, hospitals, workplaces, residential areas etc. Health promotion needs to be built into all the policies and if utilized efficiently will lead to positive health outcomes.

Keywords: Health promotion, mainstreaming health promotion, healthy public policy, issue based approach, healthy settings

Introduction

Health promotion is more relevant today than ever in addressing public health problems. The health scenario is positioned at unique crossroads as the world is facing a ‘triple burden of diseases’ constituted by the unfinished agenda of communicable diseases, newly emerging and re-emerging diseases as well as the unprecedented rise of noncommunicable chronic diseases. The factors which aid progress and development in today's world such as globalization of trade, urbanization, ease of global travel, advanced technologies, etc., act as a double-edged sword as they lead to positive health outcomes on one hand and increase the vulnerability to poor health on the other hand as these contribute to sedentary lifestyles and unhealthy dietary patterns. There is a high prevalence of tobacco use along with increase in unhealthy dietary practices and decrease in physical activity contributing to increase in biological risk factors which in turn leads to increase in noncommunicable diseases (NCD).(1–3) Figure 1 below illustrates how lifestyle-related issues are contributing to increase in NCDs.(4) The adverse effects of global climate change, sedentary lifestyle, increasing frequency of occurrence of natural disasters, financial crisis, security threats, etc., add to the challenges that public health faces today.

Figure 1

Illustration of how lifestyle-related issues contribute to increase in noncommunicable diseases(4)

Health, as the World Health Organization (WHO) defines, is the state of complete physical, social and mental well being and not just the absence of disease or infirmity. The enjoyment of highest attainable standard of health is considered as one of the fundamental rights of every human being.(5) Over the past few decades, there is an increasing recognition that biomedical interventions alone cannot guarantee better health. Health is heavily influenced by factors outside the domain of the health sector, especially social, economic and political forces. These forces largely shape the circumstances in which people grow, live, work and age as well as the systems put in place to deal with health needs ultimately leading to inequities in health between and within countries.(6) Thus, the attainment of the highest possible standard of health depends on a comprehensive, holistic approach which goes beyond the traditional curative care, involving communities, health providers and other stakeholders. This holistic approach should empower individuals and communities to take actions for their own health, foster leadership for public health, promote intersectoral action to build healthy public policies and create sustainable health systems in the society. These elements capture the essence of “health promotion”, which is about enabling people to take control over their health and its determinants, and thereby improve their health. It includes interventions at the personal, organizational, social and political levels to facilitate adaptations (lifestyle, environmental, etc.) conducive to improving or protecting health.(1,2)

Health Promotion: Historical Evolution

Health promotion is not a new concept. The fact that health is determined by factors not only within the health sector but also by factors outside was recognized long back. During the 19th century, when the germ theory of disease had not yet been established, the specific cause of most diseases was considered to be ‘miasma’ but there was an acceptance that as poverty, destitution, poor living conditions, lack of education, etc., contributed to disease and death. William Alison's reports (1827-28) on epidemic typhus and relapsing fever, Louis Rene Villerme's report (1840) on Survey of the physical and moral conditions of the workers employed in the cotton, wool and silk factories John Snow's classic studies of cholera (1854), etc., stand testimony to this increasing realization on the web of disease causation.

The term ‘Health Promotion’ was coined in 1945 by Henry E. Sigerist, the great medical historian, who defined the four major tasks of medicine as promotion of health, prevention of illness, restoration of the sick and rehabilitation. His statement that health was promoted by providing a decent standard of living, good labor conditions, education, physical culture, means of rest and recreation and required the co-ordinated efforts of statesmen, labor, industry, educators and physicians. It found reflections 40 years later in the Ottawa Charter for health promotion. Sigerist's observation that “the promotion of health obviously tends to prevent illness, yet effective prevention calls for special protective measures” highlighted the consideration given to the general causes in disease causation along with specific causes as also the role of health promotion in addressing these general causes. Around the same time, the twin causality of diseases was also acknowledged by J.A.Ryle, the first Professor of Social Medicine in Great Britain, who also drew attention to its applicability to non communicable diseases.(7)

Health education and health promotion are two terms which are sometimes used interchangeably. Health education is about providing health information and knowledge to individuals and communities and providing skills to enable individuals to adopt healthy behaviors voluntarily. It is a combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes, whereas health promotion takes a more comprehensive approach to promoting health by involving various players and focusing on multisectoral approaches. Health promotion has a much broader perspective and it is tuned to respond to developments which have a direct or indirect bearing on health such as inequities, changes in the patterns of consumption, environments, cultural beliefs, etc.(3)

The ‘New Perspective on the Health of Canadians’ Report known as the Lalonde report, published by the Government of Canada in 1974, challenged the conventional ‘biomedical concept’ of health, paving way for an international debate on the role of nonmedical determinants of health, including individual risk behavior. The report argued that cancers, cardiovascular diseases, respiratory illnesses and road traffic accidents were not preventable by the medical model and sought to replace the biomedical concept with ‘Health Field concept’ which consisted of four “health fields”-lifestyle, environment, health care organization, human biology as the determinants of health and disease. The Health Field concept spelt out five strategies for health promotion, regulatory mechanisms, research, efficient health care and goal setting and 23 possible courses of action. Lalonde report was criticized by skeptics as a ploy to stem in the governments rising health care costs by adopting health promotion policies and shifting responsibility of health to local governments and individuals. However, the report was lapped up internationally by countries such as USA, UK, Sweden, etc., who published similar reports. The landmark concept also set the tone for public health discourse and practice in the decades to come.(7–10) Health promotion received a major impetus in 1978, when the Alma Ata declaration acknowledged that the promotion and protection of the health of the people was essential to sustained economic and social development and contributed to a better quality of life and to world peace.(5)

Conferences on Health Promotion

Growing expectations in public health around the world prompted WHO to partner with Canada to host an international conference on Health Promotion in 1986. It was held in Ottawa, and produced not only the “Ottawa Charter for Health Promotion” but also served as a prelude to subsequent international conferences on health promotion. The Ottawa Charter defined Health Promotion as the process of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental and social well being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. The fundamental conditions and resources for health are: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Health promotion thus is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well being. The Charter called for advocacy for health actions for bringing about favorable political, economic, social, cultural, environmental, behavioral and biological factors for health, enabling people to take control of the factors influencing their health and mediation for multi sectoral action. The Charter defined Health Promotion action as one a) which builds up healthy public policy that combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change to build policies which foster equity, b) create supportive environments, c) support community action through empowerment of communities - their ownership and control of their own endeavors and destinies, d) develop personal skills by providing information, education for health, and enhancing life skills and e) reorienting health services towards health promotion from just providing clinical and curative services.(11)

This benchmark conference led to a series of conferences on health promotion - Adelaide (1988), Sundsvall (1991), Jakarta (1997), Mexico-City (2000), Bangkok (2005) and Nairobi (2009). In Adelaide, the member states acknowledged that government sectors such as agriculture, trade, education, industry and communication had to consider health as an essential factor when formulating healthy public policy. The Sundsvall statement highlighted that poverty and deprivation affecting millions of people who were living in extremely degraded environment affected health. In Jakarta too poverty, low status of women, civil and domestic violence were listed as the major threats to health. The Mexico statement called upon the international community to address the social determinants of health to facilitate achievement of health-related millennium development goals. The Bangkok charter identified four commitments to make health promotion (a) central to the global development agenda; (b) a core responsibility for all governments (c) a key focus of communities and civil society; and (d) a requirement for good corporate practice.(12,13) The last conference in October 2009 in Nairobi called for urgent need to strengthen leadership and workforce, mainstream health promotion, empower communities and individuals, enhance participatory processes and build and apply knowledge for health promotion.

The health promotion emblem [Figure 2] adopted at the first international conference on health promotion in Ottawa and evolved at subsequent conferences symbolizes the approach to health promotion. The logo has a circle with three wings. It incorporates five key action areas in health promotion (build healthy public policy, create supportive environments for health, strengthen community action for health, develop personal skills and reorient health services) and three basic HP strategies (to enable, mediate and advocate).

  1. The outer circle represents the goal of “Building Healthy Public Policies” and the need for policies to “hold things together”. This circle has three wings inside it which symbolise the need to address all five key action areas of health promotion identified in the Ottawa Charter in an integrated and complementary manner.

  2. The small circle stands for the three basic strategies for health promotion, “enabling, mediating, and advocacy”.

  3. The three wings represent and contain the words of the five key action areas for health promotion – reorient health services, create supportive environment, develop personal skills and strengthen community action.(14)

True to its recognition of health being more influenced by factors outside the health sector, health promotion calls for concerted action by multiple sectors in advocacy, financial investment, capacity building, legislations, research and building partnerships. The multisectoral stakeholder approach includes participation from different ministries, public and private sector institutions, civil society, and communities all under the aegis of the Ministry of Health.(3)

Approaches to Health Promotion

Health promotion efforts can be directed toward priority health conditions involving a large population and promoting multiple interventions. This issue-based approach will work best if complemented by settings-based designs. The settings-based designs can be implemented in schools, workplaces, markets, residential areas, etc to address priority health problems by taking into account the complex health determinants such as behaviors, cultural beliefs, practices, etc that operate in the places people live and work. Settings-based design also facilitates integration of health promotion actions into the social activities with consideration for existing local situations.(3)

The conceptual framework in Figure 3 below summarizes the approaches to health promotion. It looks at the need of the whole population. The population for any disease can be divided into four groups a) healthy population, b) population with risk factors, c) population with symptoms and d) population with disease or disorder. Each of these four population groups needs to be targeted with specific interventions to comprehensively address the need of the whole population. In brief, it encompassed primordial prevention for healthy population to curative and rehabilitative care of the population with disease. Primordial prevention aspires to establish and maintain conditions to minimize hazards to health. It consists of actions and measures that inhibit the emergence and establishment of environmental, economic, social and behavioral conditions, cultural patterns of living known to increase the risk of disease.(15)

Figure 3

Conceptual framework for health promotion

Examples of Health Promotion in Communicable and Non-communicable Diseases

Health promotion measures are often targeted at a number of priority disease – both communicable and noncommunicable. The Millennium Development Goals (MDGs) had identified certain key health issues, the improvement of which was recognized as critical to development. These issues include maternal and child health, malaria, tuberculosis and HIV and other determinants of health. Although not acknowledged at the Millennium summit and not reflected in the MDGs, the last two decades saw the emergence of NCD as the major contributor to global disease burden and mortality. NCDs are largely preventable by effective and feasible public health interventions that tackle major modifiable risk factors - tobacco use, improper diet, physical inactivity, and harmful use of alcohol. Eighty percent of heart diseases and stroke, 80% of diabetes and 40% of cancers can be prevented by eliminating common risk factors, namely poor diet, physical inactivity and smoking.(16) Against this background health promotion as the “the science and art of helping people change their lifestyle to move toward a state of optimal health” is a key intervention in the control of NCDs. The following paragraphs showcase the application of an issue based approach of health promotion, using communicable and NCDs as examples capturing the components of individual and community empowerment, health system strengthening and partnership development.

Communicable Diseases

These diseases can be adequately addressed through health promotion approach. Here is one example:

Improving use of ITNs to prevent malaria: Insecticide-treated bed-nets (ITNs) are recommended in malaria endemic areas as a key intervention at the individual level in preventing malaria by preventing contact between mosquitoes and humans. (a) The individual level health promotion action would include providing access to ITNs and encouraging their regular and proper use every night from dusk to dawn. Available evidence points to the fact that this can be best achieved by social marketing campaigns to promote demand of ITNs. The messages should be tailored to cultural beliefs, for example the belief in some communities that mosquitoes have no role in the etiology of malaria. Distribution of ITNs to the community should ideally be followed by ‘hang up’ campaigns by trained health care workers educating the community on how to use the nets and helping them hang the nets, especially for the most vulnerable groups. (b) The community empowerment efforts, a collaborative initiative with the community to understand the cultural beliefs and behaviours and educating them about the disease would produce desirable results. There are documented examples of how women in a community empowerment program in Thailand developed family malaria protection plans, provided malaria education to community members, mosquito-control measures in a campaign, scaled-up use of insecticide-impregnated bed nets, instituted malaria control among migrant labourers, as well as activities to raise income for their families. Another program in Papua New Guinea empowered community members to take responsibility for the procurement, distribution and effective use of bed nets in the village, which led to a significant decrease in the incidence of malaria-related mortality and morbidity. (c) Strengthen health systems, integration of malaria vector control and personal protection into the health system through innovative linkages to ongoing health programs and campaigns is likely to lead to strong synergies, economies, and more rapid health system strengthening compared to new vertical programmes.. Successful examples of this include piggybacking the distribution of ITNs through antenatal care or immunization campaigns for measles and polio. (d) Partnerships are key in malaria control because of the involvement of multiple sectors. Action outside the health sector to remove barriers to the uptake of malaria prevention strategies has included lobbying for reduction or waiver of taxes and tariffs on mosquito nets, netting materials and insecticides and stimulating local ITN industries. Intersectoral collaboration has played an integral role in vector control measures for malaria prevention, including environmental modification, larval control, etc.(17)

Noncommunicable Diseases

In NCDs, two path-breaking studies need special mention. These studies are the Framingham Heart Study (started in 1951) and study on smoking among British doctor (started in 1948) have helped us in understanding how lifestyle affects various NCDs. The study in British doctors showed that prolonged cigarette smoking from early adult life tripled age-specific mortality. The excess mortality associated with smoking mainly involved vascular, neoplastic and respiratory diseases caused by smoking. The Framingham Heart Study has led to the identification of major CVD risk factors such and blood pressure, blood triglycerides and cholesterol level, age, gender and psychosocial issues (Framingham Heart Study).(18)

Cardiovascular Diseases

In the early 1970s the mortality rate from coronary heart disease was the highest in the world among men of Finland. The dietary practices of the Finnish population centered around dairy products and their food was rich in saturated fats, salt and low in unsaturated fats, fruits and vegetables. The North Karelia project, a major community-based intervention was launched in North Karelia, a fairly rural and economically poor province. This project developed comprehensive community based strategies to change the dietary habits of the population, with the main goal to reduce the high cholesterol levels in the population. The strategy focused on reduction intake of high saturated fat as well as the salt intake and to increase the consumption of fruits and vegetables. At the individual and community level, health information and nutritional counseling were made available, skills were developed, social and environmental support was provided all the while ensuring community participation. The health system was closely involved with the project. The project also developed strong partnerships with schools, health related and other nongovernmental organizations, supermarkets and food industry, community-based organizations and media. Collaborations were done with the food industry to reduce the fat and salt content of common food items such as dairy food, processed meat and bakery items. Dairy farmers were encouraged to switch to berry farming through the launching of a Berry project. The North Karelia project was extended to the entire country with the health care services also responsible along with schools and nongovernmental agencies in implementing nutrition and health education. Nation-wide nutrition education and collaboration with food industry were backed by legislative actions and were rewarded with remarkable results. Surveys showed a transformation in dietary habits with a marked reduction intake in saturated fats and salt and declared ischemic heart disease mortality declining by 73% in North Karelia and by 65% in Finland from 1971 to 1995.(19)

Diabetes Mellitus

Diabetes mellitus is one of the NCDs which has led to high rates of morbidity and mortality worldwide. Health promotion is being increasingly recognized as a viable, cost-effective strategy to prevent diabetes. The interventions at the individual and community level includes lifestyle modification programs for weight control and increasing physical activity with community participation using culturally appropriate strategies. The Kahnawake School's Diabetes Prevention Project (KSDPP) in Canada provides an example of a project that involved the local Mohawk community, researchers and local health service providers, in response to requests from the community to develop a diabetes prevention program for young children. The long-term goal of KSDPP was to decrease the incidence of type 2 diabetes, through the short-term objectives of increasing physical activity and healthy eating. Such preventive interventions have to be backed by strengthening of the health system which combines identification of high risk groups with risk factor surveillance and availability of trained primary health care providers for risk assessment and diabetes management. Online training courses offer an innovative approach to enhance health system capacity for diabetes health promotion, such as a course targeted at workers in remote indigenous communities in the Arctic to foster learning related to the Nunavut Food Guide, traditional food and nutrition, and diabetes prevention. Partnership and network development is key to the achievement of these measures. As part of the city-wide ‘Let's Beat Diabetes initiative’ in South Auckland, New Zealand the district health board with support from local government provided safe environments for physical activity by upgrading parks and worked with the food industry to provide healthier food options at retail outlets in order to reduce consumption of sweetened soft drinks and energy dense foods. Sugar-free soft drinks were made available as default options to customers, unless specifically requested otherwise. Intersectoral action on risk factors for diabetes also acts on the determinants of the other major risk factors for the NCD burden, such as heart disease, cancer and respiratory disease, hence health promotion activities aimed at reducing risk of diabetes mellitus have added advantages.(17)

Settings Based Approach to Health Promotion

The concept of ‘healthy settings’ which maximizes disease prevention through a whole system approach had emerged from WHO's Health for All strategy and Ottawa Charter. The call for supportive environments was followed up by the Sundwal statement of 1992 and the Jakarta declaration of 1997. The settings approach builds on the principles of community participation, partnership, empowerment and equity and replaces an over reliance on individualistic methods with a more holistic and multidisciplinary approach to integrate action across risk factors. The ‘Healthy Cities’ programme launched by WHO in 1986 was soon followed up by similar initiatives in smaller settings such as schools, villages, hospitals, etc.(20)

Health Promoting Schools

Health promoting schools build health into all aspects of life in school and community based on the consideration that health is essential for learning and development. To further this concept, WHO and other UN agencies developed an initiative, ‘Focusing Resources on Effective School Health (FRESH), emphasizing on the benefit to both health and education if all schools were to implement school health policies, a healthy school environment, with the provision of safe water and sanitation an essential first step, skills-based health education and school-based health and nutrition services.(21)

Healthy Work Places

Currently, globally an estimated two million people die each year as a result of occupational accidents and work-related illnesses or injuries and 268 million nonfatal workplace accidents result in an average of three lost workdays per casualty, as well as 160 million new cases of work-related illness each year.(22) Healthy work places envision building a healthy workforce as well as providing them with healthy working conditions. Healthy working environments translate to better health outcomes for the employees and better business outcomes for the organizations.(23)

Health Promotion in India

Health promotion is strongly built into the concept of all the national health programs with implementation envisaged through the primary health care system based on the principles on equitable distribution, community participation, intersectoral coordination and appropriate technology. Nevertheless, it has received lower priority compared to clinical care. The government, through the component of IEC has always strived to address the issue of lack of information, which is a major barrier to increasing accessibility of health care services.(24) The National Rural Health Mission (NRHM) called for a synergistic approach by relating health to determinants of good health such as segments of nutrition, sanitation, hygiene and safe drinking water and by revitalizing local traditions and mainstreaming the Ayurvedic, Unani, Siddha and Homeopathic systems of medicine to facilitate health care.(25) NRHM offers an excellent opportunity to target and reach every beneficiary with appropriate interventions through microplanning into district planning process.(26)

Health promotion component needs to be strengthened with simple, cost-effective, innovative, culturally and geographically appropriate models, combining the issue-based and settings-based designs and ensuring community participation. Replicability of successful health promotion initiatives and best practices from across the world and within the country needs to be assessed. Efforts have already been initiated to build up healthy settings such as schools, hospitals, work places, etc.(20,22,27) For effective implementation of health promotion we need to engage sectors beyond health and adopt an approach of health in all policies rather than just the health policy.

Conclusions

Today, there is a global acceptance that health and social well being are determined by a lot of factors which are outside the health system which include inequities due to socioeconomic political factors, new patterns of consumption associated with food and communication, demographic changes that affect working conditions, learning environments, family patterns, the culture and social fabric of societies; sociopolitical and economic changes, including commercialization and trade and global environmental change. To counter the challenges due to the changing scenarios such as demographic and epidemiological transition, urbanization, climate change, food insecurity, financial crisis, etc. health promotion has emerged as an important tool; nevertheless the need for newer, innovative approaches cannot be understated. A multisectoral, adequately funded, evidence-based health promotion program with community participation, targeting the complex socioeconomic and cultural changes at family and community levels is the need of the hour to positively modify the complex socioeconomic determinants of health.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

References

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Health Canada
2003
ISSN 1499-3503 (Online)

Table of Contents

Since the late nineteenth century, the federal government has worked to address the health needs of Aboriginal people. Although much progress has been made, Aboriginal people as a population do not have the saure level of health as other Canadians. Among other health disparities, they have disproportionately high rates of injury, suicide and diabetes.

Today, through the First Nations and Inuit Health Branch (FNIHB), Health Canada works with its First Nations and Inuit partners to provide a wide range of health prevention and promotion activities and public health services on First Nations reserves and in identified Inuit communities. In remote and isolated areas, where provincially or territorially insured services are not readily available, on-reserve primary and emergency tare services are delivered by the branch. Non-insured health benefits, such as pharmaceutical and dental coverage, are provided to status First Nations and eligible Inuit irrespective of their residence.

Over the last two decades, FNIHB has been working with First Nations and Inuit communities to transfer control of community-based health programs to the communities. This transfer of control occurs at a pace set by individual communities. The Transfer process allows communities to participate in program design, implementation and operational activities that address their specific needs.

In addition to the work of FNIHB, the department's Population and Public Health Branch (PPHB) offers programs that target certain populations, including First Nations living off reserve, Métis and Inuit. PPHB's Aboriginal Head Start in Urban and Northern Communities Program is specifically designed for Aboriginal people, while other programs, such as the Community Action Program for Children and the Canada Prenatal Nutrition Program, have large numbers of Aboriginal participants.

Beyond the programs and services offered by Health Canada, the provinces and territories are responsible for providing physician and hospital care to Aboriginal people.

This issue of the Health Policy Research Bulletin focuses on collaborative efforts aimed at closing the gaps in health status between Aboriginal people and other Canadians. It examines the importance of culturally relevant health programs and services and the role that Aboriginal women play in the health of their communities. As well, two case studies highlight some of the ways Health Canada works in partnership with Aboriginal people to improve their overall health status.

About the Health Policy Research Bulletin

Health Canada's Health Policy Research Bulletin is published three times a year. The Bulletin is part of a la policy research dissemination program designed to enhance Health Canada's policy-relevant evidence base.

A departmental steering committee guides the development of the Bulletin. The committee is chaired by Cliff Halliwell, Director General of the Applied Research and Analysis Directorate (ARAD) of the Informatic Analysis and Connectivity Branch. The Research Management and Dissemination Division (RMDD) within ARAD coordinates the Bulletin's development and production. RMDD would like to thank the steering committee members for their contributions, as well as Nancy Hamilton and Linda Senzilet, Managing Editors, Jaylyn Wong, Assistant Editor, and Raymonde Sharpe, Distribution. Special thanks go to the lead jurisdiction for this issue, the Strategic Policy, Planning and Analysis Directorate, First Nations and Inuit Health Branch.

We welcome your feedback and suggestions. Please forward your comments and any address change; bulletininfo@hc-sc.gc.ca or phone (613) 954-8549 , (613) 954-0813.

Frequently Used Terms

Aboriginal People
A collective name for the original peoples of North America and their descendants. The Canadian Constitution recognizes three groups of Aboriginal peoples - Indians (First Nations), Métis and Inuit.
Indian
A term that collectively describes all the Indigenous people in Canada who are not Inuit or Métis. In Canada, the term Indian has generally been replaced with the term First Nation.
First Nation
A term that came into common usage in the 1970s to replace the word Indian, which some people found offensive. Although the term First Nation is widely used, no legal definition of it exists.
Inuit
An Aboriginal people of Arctic Canada who live primarily in Nunavut, the Northwest Territories, and northern parts of Québec and Labrador.
Métis
An Aboriginal people of mixed First Nations and European ancestry, distinct from First Nations people, Inuit and non-Aboriginal people.
Status Indians
Aboriginal people who are registered or entitled to be registered as "Indians" with the federal government, as determined by certain criteria in the Indian Act. Non-Status Indians are people who consider themselves Indians or members of a First Nation but whom the federal government does not recognize as Status Indians. In 1985, the federal government amended the Indien Act. Since then, thousands of people who had previously lost their status have been added to the Indian Register.

References

The Indian Register, Indian and Northern Affairs Canada, November 1997 (available at: http://www.ainc-inac.gc.ca/pr/info/info111-eng.php.

Health Policy Research Bulletin

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Working Together to Close the Gaps

The following article is based on an interview with Ian Potter, Assistant Deputy Minister of the First Nations and Inuit Health Branch, Health Canada. The interview was conducted by Linda Senzilet, Managing Editor of this issue of the Health Policy Research Bulletin. Special thanks for her assistance to Franca Santagati, Assistant Deputy Minister's Office, First Nations and Inuit Health Branch, Health Canada.

The evidence is fairly overwhelming that the health status of First Nations and Inuit people is not on a par with the rest of Canadians. What are these health disparities and how do you account for them?

It's true that First Nations and Inuit people have historically had a poorer health status than other Canadians. Infectious diseases, injuries, suicide, heart disease and diabetes affect the Aboriginal population at a disproportionate rate (see article on page 6). And, while there have been improvements in the life expectancy and infant mortality of Aboriginal people in recent years, their health status remains far below that of the general population. As a result, it continues to be an important focus for researchers and policy makers.

Although there are no clear answers to these continuing disparities, some factors appear relevant. First, Aboriginal people experience inequities in the conditions that determine health, such as lower quality housing, poorer physical environment, lower educational levels, lower socioeconomic status, fewer employment opportunities and weaker community infrastructure. In order to see sustained health improvements, First Nations and Inuit people need a healthy environment that includes safe housing, clean water and education. Second is geography - many Aboriginal people live in small communities located in rural and remote areas of the country where access to health care services is limited (see Figures 1 and 2).


Of First Nations and Inuit communities south of the 60th parallel, 77 percent have fewer than 1,000 people. The range of basic services offered varies with the degree of isolation and accessibility of the communities.

Figure 1: Population Size - First Nations and Inuit Communities Footnote 1 

Figure 2: Degree of Isolation of First Nations and Inuit CommunitiesFootnote 2 

Four types of communities have been defined to reflect varying degrees of isolation and accessibility:

  • Non-Isolated: road access less than 90 km to physician services
  • Semi-Isolated: road access greater than 90 km to physician services
  • Isolated: scheduled flights, good telephone services, and no year-round road access
  • Remote-Isolated: no scheduled flights, minimal telephone or radio services, and no road access

Data for Nunavut Territory and the Northwest Territories are not included.

How can working together with First Nations and Inuit people address these disparities? Who should be involved?

There is great diversity in individual communities and hence in their health service needs. This is one reason why the First Nations and Inuit Health Branch (FNIHB) supports the direct involvement of First Nations and Inuit communities in the design and control of their health programs. Their participation is essential in addressing disparities in health status. The Eskasoni project in Nova Scotia is an excellent example of a successful multisectoral approach to primary health care (see article on page 14).

Our mandate at FNIHB is threefold: to assist First Nations and Inuit people in attaining levels of health comparable to other Canadians; to ensure their access to sustainable health services; and to build a health sector capacity in First Nations and Inuit communities. To accomplish this, the branch works with Aboriginal organizations at the national, provincial, regional and band levels. At the national level, the Assembly of First Nations and the Inuit Tapiriit Kanatami sit on the Branch Executive Committee. Each regional FNIHB office has an extensive system of joint committees with the regional First Nations or Inuit groups that plan and manage the programs. As well, most of our programs have First Nations and Inuit representatives on their steering committees.

Aboriginal organizations also work with other branches in Health Canada. For example, Aboriginal community members are currently participating in an evaluation of the effectiveness of Aboriginal Head Start in Urban and Northern Communities, which is funded by the Population and Public Health Branch (see article on page 17).

Why is it so important to have culturally appropriate health services available to First Nations and Inuit People?

First Nations and Inuit people view health holistically, as the product of a wide range of interconnected factors, including mental, physical, spiritual and emotional influences, as well as family and community contexts. This perspective on health is not unlike the World Health Organization's definition of health as a "state of complete physical, mental and social well-being".

To be effective in restoring or maintaining health, services need to embrace the culture of the people they serve. Therefore, culturally appropriate program design and delivery must be a focus for health programs in any community, taking into account local customs, priorities, language, foods, resources and sensitivities.

Health Canada's Aboriginal Diabetes Initiative is a good example of a culturally sensitive program. It provides a comprehensive, collaborative and integrated approach to decreasing the incidence of diabetes and its associated conditions among Aboriginal people. (The article on page 20 elaborates on the importance of culturally relevant health care.)

In recent years, control over many health programs and services has been transferred from Health Canada to First Nations and Inuit communities. How did this change come about?

The concept of transferring health programs and services has evolved over the past 30 years (see article on page 11). The first step in this evolution followed the release of a 1975 paper entitled The Canadian Government/The Canadian Indian Relationships, which set out a policy framework for strengthening Indian control of programs and services. As a result, three quarters of bands assumed responsibility for programs such as the National Native Alcohol and Drug Abuse Program (NNADAP) and the Community Health Representative Program.

Following the 1979 release of the Indian Health Policy, which recognized that First Nations and Inuit people could assume responsibility for administering any or all aspects of their community health programs, Health Canada sponsored a number of demonstration projects in various communities. These experiences became the basis for the subsequent health services Transfer process, which began in 1989. Evaluations of this process - undertaken in the early and mid-nineties - concluded that it was successful in enabling First Nations and Inuit people to design programs and allocate funds according to community priorities. The Transfer process has had other benefits for communities as well, including an increased awareness of health issues, more integration of programs with the communities' social services, education and justice sectors, and more culturally based programs.

As of January 2002, 70 percent of eligible First Nations and Inuit communities had taken on some degree of responsibility for managing their community health programs. Of these, 47 percent, representing some 283 communities, had assumed overall management, while 23 percent had taken on more limited control.

What types of decisions do policy makers face in providing health services to First Nations and Inuit people? How has past policy research informed these decisions and what type of policy research will be needed to guide future decision making?

Policy makers working in First Nations and Inuit health face the same type of decisions as policy makers working in the general health system. These include: balancing the allocation of resources across the many programs and activities; determining causality of disease and disability; and identifying the most effective interventions for promoting health or treating illness.

Recent government decisions to support the creation of the National Aboriginal Health Organization (NAHO), as well as the Institute of Aboriginal Peoples Health (IAPH) within the Canadian Institutes of Health Research (CIHR), are positive steps - both for generating new research knowledge and strengthening the links between research and policy. For instance, research on the links between social cohesion and health outcomes has significantly influenced our current policy thinking and has built support for community control of health programs.

Finally, we have opportunities to move forward on existing research gaps related to specific topics, such as chronic diseases and environmental contaminants.We may need to try different ways of conducting research, especially in vey' small communities where conventional approaches may not be appropriate. In the end, our policy decisions must continue to be based on the evidence provided by our research partners and made with the collaboration and participation of First Nations and Inuit individuals, communities and organizations.

The Health Status of First Nations People in Canada

Adam Probert and Robert Poirier Strategic Policy, Planning and Analysis Directorate, First Nations and Inuit Health Branch, Health Canada

* Terms appearing in bold type are defined at the end of the article.

First Nations people of all ages have a poorer overall health status than the rest of Canadians. Furthermore, there are major disparities in health status within the First Nations population itself related to gender, age and location of residence. High quality health data is essential to improving the health status of First Nations people.

How do First Nations People Compare with Canadians as a Whole?

First Nations People Living On Reserve

In 2000, life expectancy at birth for First Nations males and females in Canada was 68.9 years and 76.6 years, respectively, compared to 76.3 years for males and 81.8 years for females in the Canadian population.* Despite these gaps, First Nations life expectancy has improved considerably since 1980, increasing by 8.0 years for males and 8.6 years for females.Footnote 3

The 1999 age-standardized death rates for First Nations people exceeded the 1998 rates for the Canadian population for the following causes of death: endocrine and immune disorders, digestive diseases, and injuries and poisonings. After age standardizing the First Nations death rates to the 1991 Canadian population, circulatory diseases surpassed injuries as the leading cause of death. This is because the Canadian population as a whole is older than the First Nations population and circulatory diseases are more common in older age groups.

In 1999, the age-standardized death rate from endocrine and immune disorders (including deaths related to diabetes) was 1.5 times higher among First Nations. The impact of diabetes in First Nations communities is even more pronounced when considering the age-standardized prevalence "rate" for diabetes among First Nations people. In all age categories and for both genders, the rate is three to five times higher than that of the Canadian population.Footnote 4 Of particular concern is the increasing incidence rate of Type 2 diabetes, which is now occurring in children as young as 5 to 8 years, although it was previously limited to the adult population.Footnote 5, Footnote 6

The First Nations death rate for injuries and poisonings is 2.9 times higher than the Canadian rate. In British Columbia, between 1991 and 1997, the First Nations population experienced eight times more fire-related deaths, four times more drownings, five times more homicides and three times more fatal falls than all residents of the province combined.Footnote 7

In 1997, the tuberculosis rate among First Nations was eight times higher than that for the Canadian population. One reason for this is the overcrowded housing conditions in many communities that may increase the risk of exposure to infected individuals (see Figure 1).Footnote 8 Footnote People living in overcrowded conditions are also more likely to have other risk factors for tuberculosis, such as poverty, living in a remote area, substance abuse and various underlying medical conditions. Communities with overcrowded housing conditions, inadequate sewage disposal and lack of running water are also at increased risk for outbreaks of hepatitis A. Figure 2 shows the rates of selected infectious diseases for the First Nations and Canadian populations.Footnote 9 

Footnote (See also article on shigellosis in Health Policy Research Bulletin, Issue 4, page 15.) One statistic that is not shown is the 1999 incidence rate for chlamydia, which was seven times higher in First Nations living on reserve than for all Canadians.

Figure 1: Total Population and Tuberculosis Incidence Rate by Community Housing Density, 1997-1999

Figure 2: Selected Infectious Diseases in the First Nations On Reserve and Populations Canadian Populations, 1999

About the Data

Statistics quoted in this article were collected in 1999 and will soon be published in Health Canada's 2003 report A Statistical Profile on the Health of First Nations in Canada,Footnote 10 unless otherwise specified. British Columbia and Alberta only report data for Status Indians within the province as a whole (both on and off reserve).

Most provinces have some degree of under-reporting for several or all indicators. Unfortunately, very little health information on Inuit is routinely collected and forwarded to Health Canada. Some jurisdictions, including Québec, the Northwest Territories and Nunavut, report health data on all residents combined. As a result, information on Inuit-specific health status is not presented here.

Aboriginal People Living Off Reserve

The 2000-2001 Canadian Community Health Survey (CCHS), conducted by Statistics Canada, compared the self-reported health status of Aboriginal people living off reserve with that of the non-Aboriginal population living in the same urban, rural and territorial communities.Footnote 11 The off-reserve Aboriginal population reported lower levels of education and household income, higher rates of smoking, drinking and obesity, and lower rates of physical activity. Even when controlling for socioeconomic status and health behaviours, the off-reserve Aboriginal population reported significantly higher rates for the following measures: self-rated "fair" or "poor" health; having more than one chronic condition; and having had a major depressive episode in the previous year. The prevalence rate for diabetes in the off-reserve Aboriginal population was twice that of the non-Aboriginal population.

How Does Health Status Vary Within the First Nations People?

By Gender

The 1999 crude death rate for First Nations males was 30 percent higher than for First Nations females, largely due to higher rates of intentional and unintentional injury. The leading causes of death by injury among males were suicides, motor vehicle accidents, suffocation and drowning, and homicide. Circulatory disease was the second leading cause of death.

Among First Nations females, the leading cause of death was circulatory disease, followed closely by injuries and poisoning. Together, these accounted for almost half of all female deaths. Females were more likely to die from motor vehicle accidents than suicides. As in the Canadian population, the rates of completed suicides were much higher among First Nations males than females, although females attempted suicide far more often than males.Footnote 12

The 1999 rate of diabetes-related deaths among First Nations females was 26.8 percent higher than among First Nations males. Approximately two thirds of all First Nations people diagnosed with diabetes were female,Footnote 13 unlike the Canadian population, in which males were more likely to be diagnosed with diabetes than females.Footnote 14

By Age Group

Figure 3 shows the leading causes of death for the Canadian population and among First Nations living on reserve.Footnote 15  When the death rates were age standardized, circulatory disease was the leading cause of death, followed by cancer and injury. For all causes of death except cancer and circulatory disease, the First Nations death rate was higher than the national rate, after adjusting for differences in age.

Statistics showing potential years of life lost (PYLL) are often used to illustrate the causes of premature death. (Please refer to Health Policy Research Bulletin, Issue 3, page 32, for a detailed description of PYLL.)Footnote Footnote 16  For example, if a 20-year-old dies accidentally, she/he has lost 55 potential years of life (using a life expectancy at birth of 75 years). Injuries have a major effect on PYLL compared with other causes of death, as they occur in all age groups, while many other causes of death are associated with aging (see Figure 4).Footnote 17 Footnote

From ages 1 to 44, the most common causes of death among First Nations were injury and poisoning. For children, these deaths are non-intentional. However, intentional injury and poisoning accounted for 38 percent of deaths among youth (10 to 19 years) and 23 percent of deaths for early adults (20 to 44 years). Motor vehicle accidents were a leading cause of death in all age categories except seniors. Even a partial reduction in the injury death rates among First Nations would have a profound effect on premature death rates and on the health of that population in general.

Figure 3: Age-Standardized Leading Causes of Death in First Nations, 1999, and in Canada, 1998


Ranking based on mortality (deaths per 100,000 population) for First Nations in 1999.

Figure 4: Potential Years of Life Lost (PYLL) by Cause, First Nations and Canada, 1999

By Geographic Location

In a Manitoba study, the prevalence of diabetes varied among First Nations people living in different provincial regions,Footnote 18 with rates as high as 25 percent in some northern Tribal Councils and as low as 15 percent in the southern Tribal Councils. (A Tribal Council is a regional group of First Nations members that delivers common services to its members.) For the province as a whole, the on-reserve prevalence rate was 20.3 percent, while the off-reserve rate was 17 percent.

The hospitalization rate for injury in the northern Tribal Councils was nearly twice the rate in the south, and almost 23 percent higher for people living on reserve compared with those living off reserve. However, premature death rates and PYLL were higher and life expectancy was lower in the south, despite generally greater access to health services. This Manitoba study reinforces the importance of considering other factors, in addition to access to health services, when describing the health and well-being of First Nations people.

Why Are Good Data Important?

The First Nations and Inuit Health Branch (FNIHB) of Health Canada administers one of the largest public health and primary care programs in Canada, delivering services to approximately 400,000 First Nations people in 640 communities and providing non-insured health benefits to an additional 300,000 First Nations living off reserve and Inuit. While there are significant gaps in First Nations and Inuit health data that need to be addressed, the existing information on the health status of First Nations helps FNIHB carry out its mandate.

There are many difficulties in collecting health information specific to First Nations people. Some of these difficulties are discussed in more detail in the article entitled "Linking Health Records" (see page 30). However, it is clear that accurate and timely health-related data are essential to understanding the health status of First Nations. Health Canada uses the data it collects to assess current national and regional health information needs regarding First Nations living on reserve. The department also obtains appropriate data from existing surveillance systems across Canada to compare health outcomes among selected populations and to identify emerging priorities. These types of information are also useful to health professionals, researchers, community leaders and policy makers for community and regional health systems planning.

The authors gratefully acknowledge the assistance of the following members of the regional FNIHB offices, particularly in the collection and analysis of health data used in this article: John David Martin (Pacific Region), Marion Perrin (Alberta Region), Lynda Kushnir-Pekrul (Saskatchewan Region), Suzanne Martel (Manitoba Region), Nicolette Kaszor (Ontario Region), Marino Argentin (Québec Region) and Susan Ross (Atlantic Region).

Glossary

Age Standardization

A statistical procedure for adjusting rates (e.g., death rates) that is designed to minimize the effects of differences in age composition when comparing rates for different populations.Footnote 19 For example, the First Nations population is a much younger population than the population of Canada as a whole. For this article, the 1991 Canadian population was used to standardize the ages of the two populations.

Canadian Population

The total population of Canada (or the specific age/sex group referred to), including the First Nations component of that population.

Crude Death Rate

An estimate of the portion of a population that dies during a specified period. The numerator is the number of persons dying during the period, while the denominator is the size of the population, usually estimated as the mid-year population.Footnote 19 It is not age-standardized and is often expressed as a rate per 100,000 persons per year.

Incidence Rate

The rate at which new events (e.g., diagnoses of a disease, suicides) occur in a population during a defined period.Footnote 19 It is often expressed as a rate per 100,000 persons per year. For example, 61.5 persons per 100,000 First Nations persons were diagnosed with tuberculosis during 1999.

Prevalence "Rate"

The proportion of a population at risk of having a disease or attribute at a particular time (or during a particular period) that actually has the disease or attribute at that time (or midway through the period).Footnote 19 It is often expressed as a rate per 100,000 persons. For example, a cross-sectional health survey can determine the number of people per 100,000 persons who currently have diabetes. (See also Health Policy Research Bulletin, Issue 1, page 18.)

Surveillance

Surveillance includes the ongoing collection of data, and the review, analysis and dissemination of findings on disease incidence and prevalence, hospitalizations and deaths. Surveillance can also collect information concerning the knowledge, attitudes and behaviours of the public with respect to practices that prevent cancer, facilitate screening, extend survival and improve quality of life. (See also Health Policy Research Bulletin, Issue 4, page 25.)

Evolving Control of Community Health Programs

Mark Wigmore, Intergovernmental Affairs Directorate, Health Policy and Communications Branch, Health Canada, formerly with Strategic Policy, Planning and Analysis Directorate, First Nations and Inuit Health Branch, Health Canada, and Keith Conn, Community Programs Directorate, First Nations and Inuit Health Branch, Health Canada

Over the past 10 years, Health Canada, through its First Nations and Inuit Health Branch (FNIHB), has forged new relationships with First Nations and Inuit communities. Aimed at improving their health status, many of these agreements have encouraged communities to take control of their health programs in order to better address local needs.

In the past decade, the role of FNIHB has evolved from service delivery to providing funding, health expertise, policy and program frameworks and other support to assist communities as they take over increasing responsibility for health care delivery with the aim of achieving better health outcomes.

How Did the Transfer of Services Come About?

Until the 1970s, federal employees delivered public health and prevention services to all First Nations and Inuit communities, as well as front-line primary care services to remote and isolated communities.

The trend towards increased involvement of First Nations and Inuit communities in the delivery of health services began with the 1979 Federal Indian Health Policy. Aimed at helping Indian communities generate and maintain improvements in their health status, the policy was based on three pillars:

  • community socioeconomic, cultural and spiritual development
  • the traditional relationship of the Indian people to the federal government (a relationship to be strengthened by encouraging greater involvement in the planning, budgeting and delivery of health services)
  • the Canadian health system (which consists of many inter-related elements that are the responsibility of the federal, provincial or municipal governments, Indian bands or the private sector)

Approximately 10 years after the Indian Health Policy, the federal government approved a health Transfer policy framework giving control of resources for community-based health programs to communities south of the 60th parallel wishing to assume this responsibility. At the same time, work continued to help the territorial governments north of the 60th parallel to assume responsibility for health care delivery.

The decision to transfer these responsibilities to First Nations and Inuit communities was the culmination of many years of discussions between the federal government and the communities, discussions that are ongoing today. Currently, more than 80 percent of the funds for federal community health programs are channeled through agreements with First Nations and Inuit organizations. Direct management of these programs and services by the federal government is becoming increasingly rare. First Nations communities now employ the majority of their community health nurses, as well as most of their addiction counselors and community health workers. Furthermore, community-based health directors manage health programs in the majority of First Nations communities. (In addition, the federal government continues to be responsible for the Non-Insured Health Benefits program, while the provinces and territories continue to provide hospital and physician care.)

"Notwithstanding that medical services are now delivered to Aboriginal people even if the remotest parts of the country ... the gap in the health and well-being between Aboriginal and non-Aboriginal people remains stubbornly wide."

Royal Commission on Aboriginal Peoples Final Report, 1996, Vol. 3

How Has Health Status Been Affected?

Part of the rationale for increasing community responsibility for health delivery is that First Nations and Inuit organizations are the best placed to understand their communities' needs and to manage and deliver health services. The empirical evidence to date on the impact of local control on health status is encouraging. A long-term evaluation conducted by Health Canada in June 1994 found that transferring management control had resulted in an increased awareness of health issues among community members and more culturally sensitive health care delivery. As well, health care had become a higher priority for the communities.Footnote 20

A British Columbia study provided further evidence of a positive impact.Footnote 21 Communities in British Columbia that were self-governing and/or had control over their health, education and other services, experienced a much lower incidence of suicide than did other communities without such control.

While more policy research on the impact of local control of health services on health status is needed, it is important to recognize that many of the factors associated with poor health status lie outside of health service delivery. Both the health determinants (population health) views expressed by governments and the holistic view of health held by many First Nations and Inuit recognize that improvements in areas such as water quality and quantity, education, employment and housing will also contribute to better health. It is certain that the engagement of First Nations and Inuit people in developing their own solutions - whether in health care or in other determinants of health - will continue to be an integral part of the strategy identified by the Royal Commission on Aboriginal Peoples and committed to by the federal government.

"The government will take further action to close the gap in health status between Aboriginal and non-Aboriginal Canadians by putting in place a First Nations Health Promotion and Disease Prevention strategy with a targeted immunization program, and by working with its partners to improve health care delivery on-reserve."

Speech of the Throne, September 30, 2002

The Eskasoni Primary Care Project

Nicki Sims-Jones Safe Environments Programme, Health Environments and Consumer Safety Branch, Health Canada, formerly with Strategic Policy, Planning and Analysis Directorate, First Nations and Inuit Health Branch, Health Canada

The Eskasoni Primary Care Project embraced a multisectoral, multidisciplinary model of primary health care in a First Nations community, which includes salaried family physicians and nursing, health education, nutrition and pharmacy services. This case study is based largely on an evaluation report authored by Mary-Jane Hampton for Health Canada in 2001.Footnote 22

An Opportunity for Change

It has been suggested that if improvements are to be made in primary health care, they are unlikely to be as a result of a "big bang" reform effort. Rather, they will come about as policy makers identify "opportunities for progressive incremental change."Footnote 23 One such opportunity for change occurred in Eskasoni, where a Primary Care Project (PCP) was implemented in 1999 as a result of multisectoral collaboration. Eskasoni, a First Nations community of 3,200 people, is located in Cape Breton, Nova Scotia. Eskasoni has a young population with few elderly people; in fact, nearly half (48 percent) of its residents are under 20 years of age. Children are encouraged to speak Mi'kmaq and are taught about their culture at home and in school. The community has been challenged by particularly high rates of death and illness associated with substance abuse and chronic diseases such diabetes, heart disease and respiratory illnesses. There is a high rate of addiction, mostly to prescription drugs. Sixty percent of adults report smoking, almost twice the rate for the province as a whole (33 percent). Forty percent of Eskasoni residents have diabetes.

1969197019751979
Federal White Paper on Indian Policy calls for an end to federal responsibility for First Nations and the termination of their special statusFirst Nations Red Paper (First Nations response to White Paper) calls for keeping their special status but with more community control of programs and servicesThe Canadian Government/The Canadian Indian Relationships Paper (policy framework for strengthening Indian control)Federal Indian Health Policy (aimed at helping Indian communities generate and maintain improvements in their health status) recognizes that Indian people may assume responsibility for administering any or all aspects of their community health programs
1983-198619881988-1989July 1989
Health Canada sponsors a number of community health demonstration projects to provide both federal and First Nations authorities with substantive information with respect to First Nation control of health servicesFinal Transfer Agreement devolves responsibility for Universal Health Programs to the Government of the Northwest Territories (NWT), while assuring that First Nations and Inuit in the NWT would continue to have access to any new federal programs for First Nations and InuitCabinet and Treasury Board approve health Transfer south of the 60th parallel (the policy framework, financial authorities and resources for transferring control of community-based health programs south of the 60th parallel to Indian communities)First Tribal Council signs a health services Transfer Agreement
199419951997April 1999
Treasury Board approves the financial authorities and resources to support the Integrated Community- Based Health Services approach (an alternative for bands that are not ready for or interested in Transfer)Inherent Right to Self-Government Policy recognizes that the inherent right to self-government is an existing Aboriginal right under section 35 of the ConstitutionYukon Territory resumes administration and delivery of Universal Health Programs in Yukon Territory, with assurance that Yukon First Nations would continue to have access to any new federal programs for First Nations and InuitNunavut Territory is created with the conditions of the 1988 Northwest Territories Final Transfer Agreement applying to the Government of Nunavut

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