NACCHO Alert : Implementing Indigenous community control in health care: lessons from Canada


” Our analysis yielded three broad lessons.

First, implementing community control takes time.

It took Canada 20 years to achieve 89% implementation. To succeed, Australia will need to make a firm long term commitment to this objective.

Second, implementing community control is complex. Communities require adequate resources to support change management.

And third, accountability frameworks must be tailored to the Indigenous primary health care context to be meaningful.”

Originally published CSIRO   Picture RedPowerMedia


Over past decades, Australian and Canadian Indigenous primary healthcare policies have focused on supporting community controlled Indigenous health organisations.

After more than 20 years of sustained effort, over 89% of eligible communities in Canada are currently engaged in the planning, management and provision of community controlled health services.

In Australia, policy commitment to community control has also been in place for more than 25 years, but implementation has been complicated by unrealistic timelines, underdeveloped change management processes, inflexible funding agreements and distrust.

This paper discusses the lessons from the Canadian experience to inform the continuing efforts to achieve the implementation of community control in Australia.

Methods We reviewed Canadian policy and evaluation grey literature documents, and assessed lessons and recommendations for relevance to the Australian context.


We conclude that although the Canadian experience is based on a different context, the processes and tools created to implement community control in Canada can help inform the Australian context.

What is known about the topic?

Although Australia has promoted Indigenous control over primary healthcare (PHC) services, implementation remains incomplete. Enduring barriers to the transfer of PHC services to community control have not been addressed in the largely sporadic attention to this challenge to date, despite significant recent efforts in some jurisdictions.

What does this paper add?

The Canadian experience indicates that transferring PHC from government to community ownership requires sustained commitment, adequate resourcing of the change process and the development of a meaningful accountability framework tailored to the sector.

What are the implications for practitioners?

Policy makers in Australia will need to attend to reform in contractual arrangements (towards pooled or bundled funding), adopt a long-term vision for transfer and find ways to harmonise the roles of federal and state governments.

The arrangements achieved in some communities in the Australian Coordinated Care Trials (and still in place) provide a model.


Internationally, primary healthcare (PHC)1 renewal continues to be identified as a key pathway to achieving health equity, meeting the needs of underserved and poorly served populations, and for improving the efficiency of healthcare systems.24

PHC services generally include four key components: (1) primary care provided by general practitioners (GPs) and, more recently, by nurse practitioners; (2) primary prevention activities (health promotion) designed to prevent the onset of illness; (3) secondary prevention interventions focused on assisting in the management of chronic illness to avoid or delay the development of complications; and (4) tertiary prevention interventions designed to assist in the management of complications, to ensure that optimal autonomy is retained.

Advocacy and referrals are integral components.1 Comprehensive PHC, the goal of Indigenous providers of health care (and some others), also emphasises the need to attend to and be informed by the social determinants of health that affect the health and life chances of the people, and their access to good health care. In this paper, the focus is on the provision of comprehensive PHC by Indigenous community-based organisations.

Evidence shows that when PHC is not accessible (geographically, economically or culturally), responsive or effective, people delay seeking help, rely on emergency care and lose the benefits of continuity of care.2,5 In many countries, histories of colonialism have resulted in power differentials that negatively affect PHC access and responsiveness to Indigenous people’s needs.

For the past 25 years, both Canada and Australia have endorsed community control of Indigenous health services, but implementation has followed different pathways. Canada has focused on transferring pre-existing PHC services previously delivered by the federal government to the established First Nations local government authorities ‘on reserves’ (i.e. for discrete First Nations communities).

In the Canadian context, community control over these services has been constrained by a disconnect between resourcing and needs, as well as some contractual inflexibilities, which, at times, undermine responsiveness.6,7 Australia has established a multiplicity of Commonwealth, state and territory funding programs for community-controlled PHC8 in response to community activism in the 1970s.

The Aboriginal Community Controlled Health Organisation (ACCHO) sector has grown substantially over the past 40 years, largely through the funding of community-initiated submissions.

In the Australian context, community-controlled PHC has been constrained by an over-reliance on short-term specific-purpose funding and inflexible contractual obligations.9

More recently, some jurisdictions have been promoting the transfer of PHC services delivered in Aboriginal communities from the state or territory health authority to an Aboriginal community-based governance structure. However, the process in both countries has been bumpy and complex.

Policies in favour of Indigenous community control clearly face implementation challenges in both countries. The aim of the present paper is to contribute to continuing efforts to achieve implementation, with a particular focus on how the Canadian experience could inform Australian implementation approaches.


Canadian challenges and strategies were reviewed, with reference to policy and evaluation documents (grey literature) that emerged over time.

The Canadian strategies were then assessed for relevance to the Australian context, recognising the common complexities of implementing community control across communities with diverse needs, capacities and experience, the challenges of formulating a meaningful accountability framework and the need for adaptation of administrative arrangements to support the delivery of responsive PHC.

Results and Discussion

In Canada, provincial governments have constitutional responsibility for the planning and delivery of healthcare services. The federal government started to assume responsibility for the delivery of health services on-reserve in the 1920s,10 on humanitarian grounds (so federal policy states) or based on Treaty obligations (according to First Nations; for a more detailed discussion, see Boyer11).

By the mid-1960s, most of the 610 First Nation reserve communities had access to some level of public health and PHC services delivered by federally employed nurses and interpreters. Community Health Representatives (CHRs; the Canadian equivalent of Aboriginal Health Workers) were added to the team in the mid-1970s, along with Addiction Prevention Workers (APWs). The role of the CHRs was to assist nurses with prevention and treatment activities. CHRs and APWs were employed by the community, with funding from the federal government. This was the beginning of community control.

CHRs and APWs were employed in nearly all First Nation communities; only very small communities were not provided with this opportunity. CHRs and APWs were hired by Chief and Council, the governance structure originally created by the Indian Act in 1876.12 The Chief and Council governance structure is the equivalent of local government, and continues to be the point of contact for consultation, negotiations and, in some cases, joint decision making with other levels of government (municipal, regional, provincial or federal). Chief and Council can also, if the community wishes, exercise some control over community-based schools, health services, child protection, economic development, community infrastructure and other federally funded programs.13

In 1985, a change was made to the Canadian Constitution (Section 35) recognising the right of First Nations, Inuit and Métis’ to self-government. Greater opportunities for community control emerged as a result. Funding options include multidepartment funding agreements (MDFA), block funding agreements (BFA) and flexible funding agreements (FFA). Flexibility depends on the model chosen by the community. MDFAs are the most flexible because they bring together multiple social programs, such as health, education, child welfare, economic development, income assistance, infrastructure, housing and local governance, under a single relational agreement. In contrast, BFAs and FFAs relate to health services only. BFAs are block-funded flexible agreements signed for 3–5 years.

A new version of this option is being offered, allowing communities to sign for up to 10 years, with opportunities to add new programs as they emerge. In contrast, communities that sign an FFA must instead secure the federal government’s permission before moving funding between budgetary lines.14 These options have been relatively well received by First Nations, with 89% of the eligible 610 First Nation communities involved in one or other type of agreement as of 2008.15 Communities who are not interested or ready to engage in this process (because of a perceived lack of capacity or other priorities) continue to receive their community-based PHC from federal government employees.

Pre-existing services delivered by the First Nations and Inuit Health Branch of Health Canada (FNIHB; the Canadian equivalent of the Office of Aboriginal and Torres Strait Islander Health (OATSIH)) are being transferred to community control. Communities wanting to manage on-reserve health services simply express this interest to the federal government. Unless the community has a history of management challenges with other programs, the federal government extends bridge funding for 12 months for the community to undertake a community needs assessment and develop a community health plan.16 Funding for community health services is based on historical expenditures in that community, and this is for the most part non-negotiable.6 Once the community health plan has been approved by the federal government, community control can be implemented.

Communities can choose to sign an agreement alone or as part of a multicommunity consortium. Communities of less than 500 members are precluded from signing a BFA unless they affiliate themselves with other communities because of sustainability issues. Communities receive separate funding to undertake an evaluation of their services every 5 years. Recent work has demonstrated that First Nation-controlled services are able to deliver on health outcomes.17

The accountability struggle

Canada has struggled with issues of accountability. When community control was initially implemented, agreements included onerous reporting requirements. Local FNIHB program managers adopted pragmatic strategies to ease that burden by overlooking missing reports of little utility.7 In 1997, the Auditor General of Canada chastised FNIHB for not following up on missing reports.18 From then on, punitive measures (withholding of funding) were put in place to ensure that all reporting requirements were met.19

In 2004, the Auditor General of Canada revisited First Nations’ reporting requirements, suggesting that, in fact, these were unduly onerous, dictated by government funders rather than based on consultations, of low use for community organisations, incremental because new programs added reports without considering the overall reporting burden, failed to inform on performance and were largely unused to report to Parliament.20

The Auditor General of Canada further pointed out that ‘there’s not much point in First Nations exchanging data for dollars with the federal government when the information is of no real benefit to either party’.21 Lavoie et al.7 documented that in 2003–04, First Nations in the province of British Columbia (169 communities) produced an estimated 5813 reports to meet their accountability requirements for health services alone. They further noted that many reports were never read because FNIHB lacked the human resources to do so. First Nations and FNIHB confirmed having little use for the information collected.

A key barrier to consolidating a meaningful reporting framework has been the accountability requirements of Treasury Board of Canada Secretariat (hereafter Treasury Board), which oversees accountability for all federal programs, grants and contribution agreements. In 2006, an independent Blue Ribbon Panel appointed by the Treasury Board reviewed all grants and contributions ($27 billion CND in annual spending), including those discussed herein. They concluded that:

  1. There is a need for fundamental change in the way the federal government understands, designs, manages and accounts for its grant and contribution programs.
  2. Not only is it possible to simplify administration while strengthening accountability, but it is absolutely necessary to do the first in order to ensure the latter.
  3. Making changes in an area of government as vast and multifaceted as grants and contributions will require sustained leadership at the political and public service levels.22

To operationalise these, the Blue Ribbon Panel recommended the following.

  1. Increased respect for recipients of grants and contribution agreements, and the reframing of this relationship as a partnership.
  2. A marked simplification of the reporting and accountability regimen to reflect the circumstances and capacities of recipients and the real information needs of the federal government.
  3. Encouraging innovation, stating that ‘the goal of grants and contribution programs is not to eliminate errors but to achieve results, and that requires a sensible regime of risk management and performance reporting’.22
  4. Organising information collected so that it can serve program managers and recipients alike.

The panel noted that mechanisms other than grants or contributions are needed for the funding of essential services such as health, education and social assistance in First Nation communities because grants and contribution agreements lead to costly and unnecessary reporting burden.

The report of the Blue Ribbon Panel led to the revisions in the contribution agreements used by FNIHB discussed above. FNIHB was also tasked to consolidate reporting requirements and reduce the burden. A first iteration was produced in 2008.23,24 Another revision is underway, in consultation with First Nations provincial organisations (peak bodies for communities), to further reduce onerous requirements and include key outcome indicators developed by FNIHB.25

Lessons for Australia?

The Canadian context is very different from the Australian one. Importantly, there are no equivalents to the treaties and the Royal Proclamation of 1763 that recognised continuing Indigenous rights in Canada. Aboriginal and Torres Strait Islander peoples are not recognised in the Australian Constitution and government responsibility for Indigenous health is not defined in health law.26

Thus, there is no enduring basis for accountability by governments for improvements in Aboriginal health care, including for transferring PHC provision to community-controlled healthcare providers, despite continuing policy commitments.26,27 Further, despite earlier policy commitments to self-determination,28 the policy discourse has largely shifted away from Indigenous rights and towards a focus on ‘closing the gap’ in social, economic and health status indicators between Indigenous and non-Indigenous Australians.29

Second, First Nations are taking on pre-existing services, previously delivered by the federal government in discrete communities, whereas this is not usually the case in Australia, where community-controlled services have more often been created de novo. When taking on community control, the responsibility for the management and delivery of services is transferred to a pre-existing governance structure that has been regulated by a federal act of parliament since 1876. In contrast, Australian community-controlled health services are non-government organisations owned by the local community and incorporated under various national or state laws.

Finally, BFAs and FFAs are transfers from a single level of government. MDFAs, when associated with land claim agreements, can be tripartite agreements between the federal department in charge of First Nation health, the Ministry in charge of First Nation education, economic development, income assistance, governance etc. and the First Nation. For example, the Nisga’a Agreement, the James Bay and Northern Quebec Agreement, and the Labrador Inuit Association Agreement are legislated tripartite agreements that include provisions for self-administration of health services.30

Accountability provisions for MDFA agreements sit outside the usual grant and contribution agreement frameworks, and provide First Nations who are signatories with budgetary line flexibility across healthcare, income assistance, economic developments and other spheres of government funding. These agreements can facilitate cross-sectoral innovations focused on determinants of health. There is no equivalent in Australia (Table 1).

Table 1.  Comparison of contexts and processes for implementing community control in Canada and Australia
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Given these important differences, what then can be learned from such a different context?

Lesson 1: implementing community control takes time

As shown in Fig. 1, implementing community control in Canada to the 89% level took 20 years (1989–2008),15 despite the fact that community control was being implemented in communities with considerable engagement with the community-based healthcare services and a governance structure that had been in place since 1876. In Australia, efforts to transfer services to community control are generally conducted under tight timelines,31 which are generally not achieved, leaving a sense of failure and opportunities for allocating blame.32

Fig. 1.  Community control uptake in Canada over time: Transfer and integrated models.
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Lesson 2: supporting change management with resources

As discussed above, the federal government initially funds First Nations for 12 months to develop a community health plan that reflects community-identified priorities. Every 5 years, the same organisations receive funding to undertake an evaluation of their services, which is used to adjust the community health plan before renewal. Research suggests that this change management cycle is key to ensuring continuous improvement.7

Lesson 3: tackling the thorny issue of accountability

Canada is slowly developing tailored mechanisms designed to fund First Nation health organisations. Accountability frameworks based on meaningful indicators are attached to the funding mechanisms. Although the work is far from complete, tailored administrative instruments are more likely to yield meaningful information that can be used by federal and First Nation program managers to ensure that services deliver on their objectives.

This work needs to happen in Australia as well, but there are significant barriers. The problems of low levels of trust across cultures, and the continuing effects of histories of dispossession and conflict are important factors. However, they are common to both countries. We suggest that there are three major barriers that differentially affect approaches to the implementation of community control in Australia.

Current contractual arrangements are illequipped to deliver PHC outcomes

The first barrier stems from the fact that Australia embraced the contractual approaches of new public management (NPM) more thoroughly than Canada,33 which means that moving to an approach that meets the needs of PHC is more difficult. Evidence shows that over-reliance on NPM-informed contractual agreements is unhelpful to local governance in rural and remote Indigenous communities.34

In funding PHC, this approach, with its focus on tendering predefined specific health interventions, has also been found to be a poor fit9,35 because PHC requires continuity of care and long-term trust-based relationships between healthcare providers and clients. A model for such a funding arrangement exists in the agreement still in place for Katherine West Health Board in the Northern Territory (a funds-pooling arrangement originally established as part of the Coordinated Care Trials36).

Implementing sustainable and effective community control in Australia will take time, and success requires a longterm vision and resources for change

In many rural and remote Australian Aboriginal communities, where the jurisdictional health authority provides basic primary care, transfer to community control will require careful community processes of development and agreement making in order to establish a structure and plan for local or regional ownership and delivery of PHC.

This needs to be supported in policy and guidelines, resourced and factored into timelines. So far, and in the context of the legacy of dispossession and community dislocation, Australian governments have underestimated the amount of work and time required.32 Political commitment that endures beyond election cycles is also needed.

Accountability on both sides

The more complex mix of funding and regulatory roles between levels of government in Australia means that no government holds enduring responsibility for Aboriginal and Torres Strait Islander health, and thus no government holds clear accountability for improvement.26

Although constitutional reform may be required to fully address this issue, other solutions include: (1) the allocation of responsibility for PHC to the federal government, as recommended by the National Health and Hospital Reform Commission;37 or (2) federal and state agreements enacted in matching legislation, clarifying roles and responsibilities and harmonising contractual and accountability requirements.26

Recognition that administrative simplification is necessary in order to strengthen accountability, as articulated in the Blue Ribbon Panel report to the Canadian Treasury Board,22 could provide the basis for the reform of approaches to funding contracts in Australia. The development of a national system of meaningful indicators of health care effectiveness in PHC for Aboriginal people38 is an important step in that direction.

Accountability by ACCHOs to their communities is structured into the sector by community ownership, but enactment and reporting of that accountability (for quality and access, good governance and responsiveness to community priorities) is less visible. The sector is actively working on methods to address this requirement (see, accessed 4 September 2015).


Current efforts to facilitate the development of the community-controlled sector in Australia stand to make a unique contribution to closing the gap in Aboriginal and Torres Strait Islander health. Canada has been engaged in a similar process for over 20 years, and the available evidence indicates that the gap can be narrowed with effective community-controlled PHC.17

The Canadian context is different, and we do not believe Canadian solutions will fit the Australian context exactly. Still, Canada’s experience can inform the implementation of community control in Australia.



NACCHO international research alert: In Canada language, culture key to improving the health of Aboriginal children


Dr. Dawn Martin-Hill


Dr. Dawn Martin-Hill is a Mohawk of the Wolf Clan, holds a PhD in cultural anthropology, lives on Six Nations and is one of the founders of the indigenous studies program at McMaster University.

Improving the health of Aboriginal children requires teaching them about their traditional languages and culture, says anthropologist Dawn Martin-Hill.

Martin-Hill was speaking to an indigenous children’s health symposium put on by university medical students Saturday at McMaster Innovation Park.

Its purpose was to examine why the quality of health of aboriginal children is so much worse than other young Canadians — and to consider solutions.

Ongoing and systemic racism within the medical profession was a major reason raised.

So too was a deep distrust of doctors by Aboriginals, something passed down through generations that stems from trauma at their hands in residential schools, or in practices such as sterilizing native women, Martin-Hill said.

And yet there was a time in history when the colonizers relied on aboriginal medicines, ways and traditions to survive, Martin-Hill pointed out.

Children and youth make up more than 48 per cent of Canada’s aboriginal population.

They suffer from higher rates of infant mortality, poverty, diabetes, tuberculosis and fetal alcohol syndrome than non-aboriginal children and lag in access to health care.

A 2009 UNICEF report on children ranked Canada third out of 177 countries in prosperity and welfare, but if the First Nations communities were considered on their own, the ranking slips to 68th.

Martin-Hill is a Mohawk of the Wolf Clan, holds a PhD in cultural anthropology, lives on Six Nations and is one of the founders of the indigenous studies program at McMaster University.

“Elders see traditional medicine as the primary tool for health restoration,” Martin-Hill said, adding that with youth forming almost half of Canada’s aboriginal population it is imperative changes happen now. “Traditional medicine and identity are important.”

Martin-Hill said the natives of Akwesasne territory have been the most proactive at restorative health so far by using traditional methods of intervention, bringing back rituals “to reseed our identity” and the rights of passage into manhood and womanhood where family and community lends support in much the way “a village” raises a child.

It’s about teaching children empowerment through traditional methods, she said.

“We need to start with the teenage population making healthy choices, and with all the supports they need.”

Through research and study, Martin-Hill said, it has become clear that native language is the primary protective factor of children’s health.

“I know it’s hard to fathom,” she said, adding that the B.C. interior communities able to keep their languages and traditions due to their remote locations, far from agents and missionaries, fared best in children’s health.

Martin-Hill said there are no biological reasons for suicides and diabetes being higher in aboriginal children — other than the historical trauma that has made its way through the generations, including children being torn from their homes and sent to residential schools.

“We need Canadians to really understand our history and our goals of being self-determining.”

With supports and following indigenous, community-driven initiatives, “we could start to lessen these disparities.”


NACCHO resources library: Conducting research with Aboriginal people and communities: Research Brief 2013


Past critiques of the social sciences focused primarily on the identity of the researcher and his or her relationship with the ‘subject’ Indigenous person, but over time more sophisticated and practical approaches have emerged related to participant-focused methodologies and design.

Download report here

NACCHO has developed an extensive online library and welcomes research and publications to share

More specifically, past research involving Indigenous people has been criticised as inherently biased and disempowering (Henry et al 2004; Davey and Day 2008; Kidman 2007; Sherwood 2010).

Recent responses that seek to improve all forms of research practice involving Indigenous people in Australia and internationally, include funding for Indigenous-specific research institutes, dedicated funding for Indigenous academics and research networks, and ethical guidelines.

Some of the most interesting and substantial Indigenous-led or informed research that has emerged in the past 20 years has often related to health, although such innovative approaches remain under-developed in the criminological domain.

Today, Indigenous researchers argue the focus should be on working with Indigenous people who hold the knowledge and expertise of their circumstances past and present, and on positive change (Smith 1999; Sherwood 2010).

This brief provides an overview of innovative and exemplary research approaches and practice undertaken with and by Indigenous communities that is relevant to crime and justice research.

A number of critical questions guided this brief, including:

  1. What have been the research topics and methods undertaken in Australia in recent years on justice issues and Indigenous people?
  2. What constitutes good practice in criminological research and evaluation?
  3. What are some of the key considerations when conducting research with Indigenous people and communities?
  4. What should constitute good practice and what are examples?
  5. What are the main practical challenges associated with such practice?

The brief is divided into four sections, covering research practice and context, ethical frameworks and review processes, practical constraints and challenges, and promising practice.

Where appropriate, examples are drawn from other countries, most notably New Zealand and Canada.

NACCHO-PRESS TV:Canadian Aboriginals facing health care discrimination

Press tv

What can the Australian Aboriginal controlled health movement learn from the Canadian experience?
Please leave your COMMENTS below
“According to the report, while factors like poverty and the impact of colonization are known to have an impact on Aboriginal health, a “Western approach to health care” seems to be reinforcing stereotypes, alienating and intimidating patients.”
The  facts are outlined in a 74-page document titled “empathy, dignity and respect,” The Health Council of Canada released it not too long ago and what it is shows is Aboriginal Canadians face racism and stereotyping when it comes to obtaining health care all throughout the country. Pamela Shauk heads The Native Friendship Centre of Montreal, a non-profit helping to improve he life in the Urban Aboriginal community of Montreal.

Now the independent national agency is calling for “culturally competent” care and environments in which aboriginal patients can be treated with understanding and respect.”

But even so doubt looms among Aboriginals and other Canadians.

The report was based on meetings with health care providers across the country, many of whom were aboriginal.The Health Council of Canada says when Aboriginal patients arrive whether it’s in an emergency room or in any health centre — they’re not necessarily seen for who they are and consequently not respected, and are not treated as fellow human beings.

Because of it, Aboriginal patients are now avoiding care or drop out of treatment programs.The situation is all the more concerning because aboriginal people often have poorer health and shorter life expectancies than other Canadians.

According to the report, while factors like poverty and the impact of colonization are known to have an impact on Aboriginal health, a “Western approach to health care” seems to be reinforcing stereotypes, alienating and intimidating patients.

Empathy,dignity,and respect:Creating cultural safety for Aboriginal people in Canada’s urban health care

Canada Aboriginal_Report-Cultural safety_Page_01


• Cultural competency is about creating a health care environment that is free of racism and stereotypes, where Aboriginal people are treated with empathy, dignity and respect.

• Cultural safe care involves building trust with Aboriginal patients and recognizing the role of socioeconomic conditions, history, and politics in health.

You can download report here (released December 2012)

View the report VIDEO on NACCHO TV -YouTube

Full information from Health Canada website


Demographics and health indicators of Aboriginal People

• Evidence indicates a continuation of gaps in health status between Aboriginal people and the larger Canadian population

• As a group, Aboriginal people have the poorest health outcomes and the shortest life expectancies of all Canadians

• As a whole, the Aboriginal population in Canada is younger than the non-Aboriginal population1

• The birth rate among the overall Aboriginal population continues to be much higher than for the general population1

– Aboriginal women have on average 2.6 children over their lifetime, while the average for women in Canada as a whole is 1.52

• Approximately half of Canada’s 1.3 million Aboriginal people live in cities

Aboriginal Disparities

• There are significant overall health and socio-economic disparities between Aboriginal and the larger Canadian population. First Nations, Inuit and Métis populations:

– Aboriginal children are more likely to die in the first year of life

– have a higher burden of chronic health conditions and infectious diseases

– are more likely live in poor health and die prematurely

– are less likely to graduate from high school and more likely to be unemployed

– are more likely to live in poverty which contributes to higher incidence of poor nutrition, obesity and living in overcrowded and substandard housing

It is well documented that many underlying factors negatively affect the health of Aboriginal people, including racism and negative stereotypes that are entrenched in society.


You can download report here

View the report VIDEO on NACCHO TV -YouT