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Social Science & Medicine xxx (2010) 1e8

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Social Science & Medicine

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

Josée Gabrielle Lavoie a,*, Evelyn L. Forget b, Tara Prakash b, Matt Dahl c, Patricia Martens b, John D. O’Neil d

aUniversity of Northern British Columbia, Health Sciences Programs, 3333 University Way, Prince George, BC V2N 4Z9, CanadabDepartment of Community Health Sciences, University of Manitoba, CanadacManitoba Centre for Health Policy, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba, Canadad Faculty of Health Sciences, Simon Fraser University, Canada

a r t i c l e i n f o

Article history:Available online xxx

Keywords:CanadaFirst NationsIndigenousPrimary health careEquityPolicyParticipationGeneralized linear equationsEthnicity

* Corresponding author. Tel.: þ1 250 960 5283; faxE-mail address: jlavoie0@unbc.ca (J.G. Lavoie).

0277-9536/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.socscimed.2010.04.037

Please cite this article in press as: Lavoie etScience & Medicine (2010), doi:10.1016/j.soc

a b s t r a c t

The objective of this study was to document the relationship between First Nation’s community char-acteristics and the rates of hospitalization for Ambulatory Care Sensitive Conditions (ACSC) in theprovince of Manitoba, Canada. A population-based time trend analysis of selected ACSC was conductedusing the de-identified administrative data housed at the Manitoba Centre for Health Policy, includingvital statistics and health information. The study population included all Manitoba residents eligibleunder the universal Manitoba Health Services Insurance Plan and living on First Nation reserves between1984/85 and 2004/05. Twenty-nine ACSC defined using 3, 4 and 5 digit ICD-9-CM and ICD-10-CM codespermitted cross-sectional and longitudinal comparison of hospitalization rates. The analysis usedGeneralized Estimated Equation (GEE) modeling.

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

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

� 2010 Elsevier Ltd. All rights reserved.

Introduction

Studies have repeatedly reported that the health of Indigenouspeoples world-wide is poor, reflecting colonial and post-colonialpolicies that undermined Indigenous peoples’ cultures, languagesand social structures, and resulted in widespread economicmarginalization (Anderson et al., 2006; Stephens, Porter, Nettleton,& Willis, 2006). In recent decades, Indigenous peoples in manycountries have sought to secure more control over community-based health services, in the hope of improving access andresponsiveness (United Nations, 2002). This is seen by Indigenouspeoples as an expression of their Treaty right (as in New Zealand)and/or Indigenous rights to self-determination (Laing & Pomare,1994), rights that survived colonisation (especially in Canada and

: þ1 250 960 5744.

All rights reserved.

al., Have investments in on-rscimed.2010.04.037

New Zealand, see Havemann, 1999 for a detailed discussion).Governments have responded by developing contractual relation-ships with Indigenous health organizations that provide a spec-trum of primary health care services, ranging from healthpromotion and prevention, to primary intervention and rehabili-tative services (Lavoie, Boulton, & Dwyer, in press). This shift echoesthe Alma-Ata Declaration and the Ottawa Charter’s commitment topopular engagement in service planning and delivery (WorldHealth Organisation & UNICEF, 1978, 1986; World HealthOrganisation Department of Communicable Disease Preventionand Health Promotion, 1997).

In Australia, the number of Indigenous primary health careproviders has grown to approximately 150 since they first emergedin 1971 (Dwyer, O’Donnell, Lavoie, Marlina, & Sullivan, 2009). InNew Zealand, the sector grew from 23 providers in 1993e240 in2007 (New Zealand Ministry of Health, 2007). In Canada, HealthCanada reports that as of March 2008, 83 percent of eligible FirstNation communities are involved in managing their own

eserve health services and initiatives promoting community..., Social

J.G. Lavoie et al. / Social Science & Medicine xxx (2010) 1e82

community-based health services (Health Canada (FNIHB), 2008).Although community members have reported improvements inoutcomes (Lavoie et al., 2005), the magnitude of these improve-ments is not known. Likewise, despite international commitmentsto the ideal of community participation in the planning anddelivery of primary health care services, empirical studiesdemonstrating the linkage between community engagement andoutcomes remain inexistent. Perhaps as a result, “if some keyprinciple of Alma-Ata has been lost more than any other, it is that ofcommunity participation” (Lawn et al., 2008, p. 924).

The objective of this study was to investigate the relationshipbetween models of community control, on-reserve access toprimary health care services and health outcomes among FirstNations living in the province of Manitoba, Canada. Manitoba wasselected for this study because along with Saskatchewan, Manitobais home to highest proportion of First Nation peoples in Canada, atnearly ten percent of the provincial population (Statistics Canada,2008). Second, Manitoba is unique in Canada and among othercountries in that works in partnership with the Assembly of Man-itoba Chiefs who represents First Nations the Manitoba Centre forHealth Policy of the University of Manitoba which houses thePopulation Health Research Data Repository (herein referred to asthe Repository). The Repository consists of provincial administra-tive databases which are longitudinal, de-identified yet linkable atthe person level. This resource facilitates health research in areasthat are of relevance to First Nations. Finally, this study was iden-tified as a priority research area by the Assembly of ManitobaChiefs.

Conceptual framework

In this study, we conceptualize that health disparities orinequalities exist whenever the health of First Nations lags behindthat of other Canadians (Whitehead, 1992). Determinants gobeyond access to care, and include other factors such as a history ofoppression, genetic make-up, lifestyle choices, socio-economicconditions, environment, education, housing, etc. (Adelson, 2005;Marmot & Wilkinson, 1999; Reading, Kmetic, & Gideon, 2007).For the purpose of this study, we are concerned with healthinequalities that can be addressed through primary health careinterventions. Although the exact role primary health care can playin addressing health inequalities is limited (Marmot & Wilkinson,1999), reviews by Starfield, Shi, and Macinko (2005) andMacinko, Starfield, and Shi (2003) suggest that better access toprimary care and primary prevention is associated with improvedaccess to immunization; smoking cessation; better prenataloutcomes; decreased childhood morbidity; earlier detection ofmelanoma and breast, colon and cervical cancers; improvedoutcomes for patients with type II diabetes mellitus, hypertensionand depression; improved management of asthma; and decreasedall-causes of mortality.

The need for primary health care intervention can conceptuallybe defined as the ability or capacity to benefit from healthinterventions. These benefits may be in the form of an improve-ment, restoration, maintenance or protection of health status(Mustard & Derksen, 1997). For the purpose of this study, we havedefined outcomes in terms of hospitalization for Ambulatory CareSensitive Conditions (ACSC). These are conditions defined as, “(t)hose diagnoses for which timely and effective outpatient [primary]care can help to reduce the risks of hospitalization by either pre-venting the onset of an illness or conditions, controlling an acuteepisodic illness or conditions, or managing a chronic disease orcondition” (Billings et al., 1993). Hospitalizations for these diag-noses may therefore indicate a potentially preventable complica-tion resulting from limited access to responsive primary health

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care services. Further, the documented disproportionate rate ofhospitalization for ACSC among First Nations when compared toother Manitobans (Martens, Sanderson, & Jebamani, 2005)suggests possible inequity in access to primary health care, andthe need for investment. This indicator has been endorsed byresearchers and policy makers as a dependable indicator of theperformance of primary health care services (Canadian Institutefor Health Information, 2006, 2007; Marshall, Leatherman, &Mattke, 2004).

Local access to care

In the First Nation context, on-reserve primary health careservices are funded and were historically delivered by the FirstNations and Inuit Health Branch of Health Canada (FNIHB). Broadlyspeaking, the current complement of on-reserve health services isbased on a 1969 study (Booz Allen & Hamilton Canada Ltd, 1969)that recommended a greater focus on prevention. This study’srecommendations however nested themselves in a federal policythat conceptualized the responsibility of the federal government ascomplementary to what services were available from provincialgovernments. What emerged is a four-level framework thatconstitute the basis of FNIHB funding of on-reserve health services,based on community size, level of remoteness and access toprovincial services, as shown in Table 1. This is generally referred toas facility designation.

Communities considered to have reasonable access to provincialhealth care services in nearby communities are funded to offerscreening and preventive services on a part-time basis (healthoffices). Communities located within a 2-h drive from provincialservices are funded to ensure local access to preventive, screeningand emergency care. These services, delivered through healthcentres, focus on primary prevention, with some level of secondaryprevention interventions. There is no or limited funding to ensureoff-hours coverage. More isolated communities served by nursingstations, are funded to ensure local access to screening, prevention,emergency and treatment services on a 24/7 basis, delivered bynurses with an extended scope of practice.

Previous work by Martens et al. (2005) documented that dia-betes prevalence rates are 4.2 times higher for Manitoba FirstNations compared to all other Manitobans, but the populationprevalence of amputation due to diabetes is sixteen times higher(3.1 versus 0.19 per thousand, ages 20 through 79). The studyreported the highest rate of amputations (6.2 per thousand) in FirstNation communities located in the southwest of the province.Although there are some variations, these communities areconsidered non-isolated (meaning that a general practitioner and/or a hospital is available within 2 h, and that roads are passable allyear), and served by either a health office (N ¼ 5) or a health centre(N ¼ 4). These findings suggest that geographical accessibility doesnot guarantee that services can be accessed, are accessed and/orare responsive. These findings provide an impetus to look morecarefully at the relationship between local access to care andoutcomes.

Community control

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

Under the Health Transfer approach, communities can take onthe administration of a range of community-based and regional

eserve health services and initiatives promoting community..., Social

Table 1Facility designation criteria (Health Canada (FNIHB), 2003, 2004a).

Type of Facility Community characteristics (the community should meet a majority of the following criteria)

Health office Criteria: Population: 0 to 750 total on-reserve population, non-isolated and semi-isolated community (isolated under favourable conditions). Healthservices: other health services available in nearby communities/cities, hospital accessible by road in less than 2 h. Transportation: All weather road/air access. Community infrastructure: Adequate community services.On-reserve health services funded: Part-time, often non-resident screening and prevention services only.

Health station Criteria: Population over 100 on-reserve, remote isolated to semi-isolated community, over 150 km from a service centre but within 50 km ofa nursing station or other FNIHB facility. Health services: hospital accessible by road less than 2 h, occasional unavailability of local ambulance andfirst response services. Transportation: Accessible by air or road from FNIHB facility, poor road conditions. Community infrastructure: Limitedcommunity services.On-reserve health services funded: Part-time screening and prevention services only.

Health centre Criteria: Population over 100 on-reserve. Non-isolated and semi-isolated community, less than 350 km from a service centre. Health services:hospital accessible by road less than 2 h, occasional unavailability of local ambulance and first response services. Transportation: All weather road/airaccess, poor road conditions. Community infrastructure: Limited community services.On-reserve health services funded: Emergency, screening and prevention available 5 days per week, with limited or no after hour care locally.

Nursing station Criteria: Population over 500 on-reserve. Remote or isolated community, over 350 km/3 h travel to a service centre. Health services: nearest hospitalmore than 2 h away, limited availability of local ambulance and first response services. Transportation: No year round road access to other healthcare facilities. Community infrastructure: Limited community services.On-reserve health services funded: Treatment and prevention, accessible 24/7.

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programs. The process includes the transfer of knowledge, capacityand funds so that communities can manage and administer theirhealth resources based on their own community needs and prior-ities (Health Canada (FNIHB), 2004b). Financial and humanresources are available for pre-transfer planning, for up to 21months (Health Canada (FNIHB), 2004b). Following the completionof this planning period, and the development of a communityhealth plan, communities may sign a three or five year agreement.Under these agreements, communities may design new programsand redirect resources to areas of high priority, as long as manda-tory programs (immunization, communicable disease control,environmental health) are delivered (Health Canada, 2007). Fund-ing is provided based on historical expenditures, to which is addedsome funding for administration. As a result of this additionalfunding, some communities are able to hire a full time HealthDirector from the community. This model became available tocommunities in 1989.

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

NTNI communities have somemeasure of community control, inthat a limited number of programs are managed by the community,each under a separate contribution agreement. As a result, NTNIcommunities have little latitude in priority setting and in the stra-tegic allocation of resources, but some say over implementation.Each program has its own funding formula that may be based onhistorical expenditures, proposal writing, etc. Thismodel emerged inthe late 1970s. Although the number of programs available underthis option has increased over time, so have expectations.

Finally, as a result of an Agreement signed in 1964 by thefederal and provincial Health Ministers, four Manitoba First Nationcommunities receive their clinical and public health services fromManitoba Health, through their local Regional Health Authority(RHA). In contrast, the on- and off-reserve population living in orclose to fifteen other First Nation communities was designated asfederal jurisdiction. The communities served by their RHA have noopportunity to engage in self-government activities.

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Methods

Data and sample

The project sample includes all Manitoba residents eligibleunder the Manitoba Health Services Insurance Plan living on FirstNation reserves (N ¼ 64,933 in 1984/85; N ¼ 71,510 in 2004/05).One conceptual impediment to pursuing this work to date has beenthat researchers have focused on ethnicity rather than residency ina community as the key independent variable. The current data-bases are unable to reliably show First Nation identification. Thisstudy however does not require First Nation identification, since itis concerned with services accessible to community members, andtheorizes that service availability is constrained by federal-provincial jurisdictional division of responsibilities over FirstNation primary health care services, the level of on-reserve primaryhealth care services funded, and geography (Lavoie et al., 2005).

We used six-digit postal code data in the administrative data-base to track all Manitobans to their home address to identify thepopulation served by each community. Manitoba-registered FirstNations represent 95.6 percent of the overall on-reserve population(CWIS, 2003e04 figures from FNIHB, Lavoie & Forget, 2005). Othersare non-status, Métis or non-Indigenous individuals who dependon the same services. In this study, only four communities (DakotaPlains, Dauphin River, Lake St Martin and Long Plains, with a totalpopulation of approximately 2000 individuals) could not beuniquely identified by postal code, and could not be included in thesample. We estimate the impact of this omission to be negligible.Table 2 provides a breakdown of communities per category.

Trends and patterns of health services used by residents livingon First Nation reserves were identified from fiscal years 1984/85 to2004/05 to assess the potential impact of community control andaccess to local primary health care services over time. The data usedfor this study included files in the Repository housed at the Man-itoba Centre for Health Policy in the University of Manitoba,namely: (1) Vital Statistics files; (2) the Population Health Registryfile for the provincial insured population; and (3) the hospitalrecord files. The Population Health Registry file provides demo-graphic information such as sex, age and place of residence (a 6-digit postal code), but is de-identified (i.e., no name, no completeaddress). A (new) family number is assigned when a residentbecomes 18 years of age, is married or divorced. One of the divorcedspouses, typically the woman, receives a new number. Trackingfamily numbers provides information on family composition. Thispopulation-based registry provides information on all residents in

eserve health services and initiatives promoting community..., Social

Table 2Definition of the sample.

Number ofcommunities

Total populationincluded

1984e85 2004e05 1984e85 2004e05

Level of primary health care available on-reserveNo facility 2 2 2627 1031Health office 24 24 22,631 19,225Health Station 0 0 0 0Health centre 11 11 18,542 22,933Nursing station 22 22 21,133 28,321

59 59 64,933 71,510

Prevalence of community control modelsProvincial facility (1964 agreement) 4 4 3512 3532Non-transferred/non-integrated 22 55 61421 22,069Integrated 0 7 0 10,015Transferred 0 26 0 35,894

59 59 64,933 71,510

J.G. Lavoie et al. / Social Science & Medicine xxx (2010) 1e84

a given postal code, as well as their arrival and departures (births,deaths and moves) for any date since 1970 (Roos & Nicol, 1999).Time-sensitive data (place of residence, family composition) areupdated every six months. Longitudinal or linked data are typicallyput together as needed for each study, after appropriate ethics andprivacy reviews are completed (Roos, Sooden, Bond, & Burchill,2003).

Standardized data, based on every hospital contact, aresubmitted to Manitoba Health (MH), the provincial agencyresponsible for funding provincial health care services. This infor-mation (including de-identified patient identifiers, physicianclaims, diagnoses, costs, hospitalization, and institutionalizationdata) is encrypted with a scrambled personal health identificationnumber prior to transfer to theManitoba Centre for Health Policy tobe housed in the Repository. This system allows tracking resourceutilization over time for any given patient and/or particular medicaldiagnosis, including all hospitalization data.

Measures

Dependent variablesThe key dependent variable is hospitalization for ACSC. For this

study, we developed our own definition of ACSC. We began witha definition created by the Canadian Institute for HealthInformation (2006, 2007), which is focused on an aging pop-ulation. We added components from the Victorian Government ofAustralia which is more comprehensive (Victorian GovernmentDepartment of Human Resources Division, 2001). Finally, we finetuned our definition using recent studies related to the epidemio-logical profile of First Nations in Manitoba and in Canada (Martenset al., 2002, 2005; Shah, Gunraj, & Hux, 2003). Our final definition

Table 3Definition of Ambulatory Care Sensitive Conditions (Canadian Institute for Health Inform2001).

Conditions Codes

Chronic Conditions Acute Bronchitis (only when a secondary diagno(COPD); Diabetes, Diabetes with Complications;edema; Hypertension (excluding cases with the fPneumonia (only when a secondary diagnosis of

Vaccine Preventable Conditions Diptheria; Hemophilus Influenza type B; HepatitiPertussis; Pneumococcal; Poliomyelitis; Rubella;

Acute Conditions Cellulitis (excluding cases with the following surglisted); Dental Conditions; Gastroenteritis; PelvicSevere ENT (Ear, Nose, Throat) Infections (exclud

a “Secondary diagnosis” refers to a diagnosis other than most responsible.b Code may be recorded in any position. Procedures coded as cancelled, previous and

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includes three categories of ACSC: chronic; vaccine preventable;and acute conditions, as listed in Table 3. Each condition wasdefined based on the International Classification of Diseases. The1984/85 to 2003/04 hospital data uses the ICD-9-CM codes; the2004/05 uses the ICD-10-CA codes. We used 3, 4 and 5 digit codesdepending on the condition. We defined hospitalization for ACSC interms of number of hospital separation per year (continuous stay inhospital by one person). Thus, one person may have more than oneseparation per year.

Independent variablesTwo key independent variables were identified. The first focuses

on local access to primary health care. The second is based onmodels of community control. These are detailed below.

Defining on-reserve health services. We developed a database ofFirst Nation communities in Manitoba that shows the level ofcommunity control (Transfer, Integrated, NTNI, 1964 agreement), aswell as level of care classifications outlined in Table 1. Accordingly,only 22 First Nation communities in Manitoba are resourced tooffer a full complement of primary health care services (nursingstations). The remaining 35 are resourced for public healthprograms 5 days a week or less, that focus largely on primaryprevention (education) and screening. In these communities,services to those who have already been diagnosed with a chroniccondition are extremely limited. Our sample includes an additionaltwo communities that have no local access to services.

Models of community control and uptake. The analysis also includedinformation on models of community control in place in eachcommunity (as detailed above), including the year an Integrated orTransfer agreement was signed, where applicable. Trends areshown in Fig. 1.

Statistical methodA model-based approach using the generalized estimating

equations (GEE) method of parameter estimation was applied tothis data to test for differences in hospital utilization rates for ACSC.GEE are used as a method for analyzing correlated longitudinaldata. These data have measurements (hospitalizations) taken overtime (1984/85e2004/05) on subjects that share common charac-teristics (age group, gender, and community). Therefore one mayexpect the outcomes for subjects of similar age, gender andcommunity to be correlated over time.

We designed a number of models to determine whether localaccess to care and local autonomy affected ACSC hospitalizationrates. In these models, the GEE method allows us to account for thecorrelated structure of the data. We investigated whether the rateof hospitalization for ACSC differed by the type of local servicesavailable. The type of local health care provided in each community

ation, 2006, 2007; Victorian Government Department of Human Resources Division,

sis of COPD is present); Asthma; Angina; Chronic Obstructive Pulmonary DiseaseGrand mal status and other epileptic convulsions; Heart Failure and pulmonaryollowing surgical proceduresb); Iron Deficiency Anemia, Other deficiency anemia;COPD is present).a

s A; Hepatitis B; Influenza; Measles; Meningococcal disease (meningitis); Mumps;Tetanus; Tuberculosis.ical procedures except incision of skin and subcutaneous tissue where it is the onlyInflammatory Disease (exclude males or cases with a hysterectomy procedure);e otitis media cases with a myringotomy procedure).

“abandoned after onset” were excluded.

eserve health services and initiatives promoting community..., Social

Fig. 1. Community control uptake over time, by category. Provincial/RHA stands for services provided in the community by the provincial Regional Health Authorities as a result ofthe 1964 agreement. NTNI stands for non-transferred/non-integrated communities, being communities that have not/yet to sign a transfer or an integrated agreement. Integratedstands from communities that signed an integrated agreement. Transfer stands from communities that signed a transfer agreement.

J.G. Lavoie et al. / Social Science & Medicine xxx (2010) 1e8 5

did not change over the period, so we examined ACSC hospitali-zation rates by category of local access to care for the period of1984/85 to 2004/05.

We also investigated the relationship between ACSC hospitali-zation rates and the level of local autonomy (as measured bywhether communities had signed Transfer agreements, Integratedagreements, or whether they relied on NTNI agreements or solelyprovincial/RHA care).

Results

Local access to care

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

Local control

We investigated whether the rate of hospitalization for ACSChospitalization was different for the different categories of

Table 4Relationship between the level of local access to primary health care (facility designatio

Label Estima

All conditions Avg. diff in rates between health centre and no facility �0.09All conditions Avg. diff in rates between health office and no facility �0.02All conditions Avg. diff in rates between nursing station and no facility �0.33All conditions Avg. diff in rates between health centre and health office �0.07All conditions Avg. diff in rates between health centre and nursing station 0.234All conditions Avg. diff in rates between health office and nursing station 0.30Acute Avg. diff in rates between health centre and no facility �0.43Acute Avg. diff in rates between health office and no facility �0.24Acute Avg. diff in rates between nursing station and no facility �0.60Acute Avg. diff in rates between health centre and health office �0.19Acute Avg. diff in rates between health centre and nursing station 0.171Acute Avg. diff in rates between health office and nursing station 0.36Chronic Avg. diff in rates between health centre and no facility 0.404Chronic Avg. diff in rates between health office and no facility 0.47Chronic Avg. diff in rates between nursing station and no facility 0.049Chronic Avg. diff in rates between health centre and health office �0.06Chronic Avg. diff in rates between health centre and nursing station 0.355Chronic Avg. diff in rates between health office and nursing station 0.42

a This estimate is the natural log value of the relative rate. As it is in this table, the tes

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autonomy (provincial/RHA, NTNI, Integrated, Transferred). For thisanalysis, we used data beginning in 1996/97, as this is the first yearall four autonomy categories were present, as shown in Fig. 1. Thismodel compared the rates of hospitalization for ACSC depending onthe level of autonomy for the time period 1997/00, to rates for the 3year period from 2002/05. As shown in Table 5, the results were notstatistically significant.

We designed a second analysis, based on the assumption thatthere may be a temporal gradient at play. Specifically, we investi-gated whether there was a significant time trend in the rates ofhospitalization for ACSC in the year following the signature of anintegrated or transfer agreement. Our results showed that aftersigning an integrated or a transfer agreement (single cluster), therates of hospitalization for ACSC decreased with each followingyear. This is true for all conditions combined (acute, chronic andvaccine preventable, (p¼ 0.0005). We also narrowed our analysis todifferentiate between chronic and acute conditions (N for vaccinepreventable conditions were too small for this analysis). Onlychronic conditions showed a significance difference (p ¼ 0.0011).These findings are shown in Table 6.

Finally, we pursued a third analysis to differentiate betweencommunities that signed an integrated agreement (lesser level ofautonomy) and those who signed a transfer agreement (moreflexibility and autonomy). Specifically, we examined whether there

n) and rates of hospitalization for ACSC.

tea Standard Error Alpha Confidence Limits Chi-Square Pr > ChiSq

96 0.1211 0.05 �0.337 0.1378 0.68 0.410945 0.1212 0.05 �0.2621 0.2131 0.04 0.839941 0.1204 0.05 �0.5701 �0.0981 7.7 0.005551 0.0392 0.05 �0.152 0.0017 3.67 0.05535 0.0344 0.05 0.1671 0.302 46.45 <0.0001

96 0.0363 0.05 0.2386 0.3807 72.93 <0.000149 0.1732 0.05 �0.7743 �0.0955 6.31 0.01244 0.1761 0.05 �0.5895 0.1007 1.93 0.165168 0.1726 0.05 �0.9451 �0.2686 12.36 0.000405 0.0549 0.05 �0.2981 �0.0829 12.04 0.00059 0.0407 0.05 0.0922 0.2517 17.86 <0.0001

24 0.0536 0.05 0.2573 0.4675 45.67 <0.00019 0.1199 0.05 0.1699 0.6398 11.41 0.0007

13 0.1189 0.05 0.2382 0.7043 15.71 <0.00014 0.1193 0.05 �0.1844 0.2832 0.17 0.6786

64 0.0512 0.05 �0.1666 0.0339 1.68 0.19435 0.0518 0.05 0.2539 0.457 47.08 <0.0001

19 0.0502 0.05 0.3234 0.5203 70.54 <0.0001

t indicates whether or not the estimate differs from 0.

eserve health services and initiatives promoting community..., Social

Table 5Analysis of community autonomy models.

Label Estimate Standard Error Alpha Confidence Limits Chi-Square Pr > ChiSq

Avg. diff in rates between Integrated and NTNI 0.064 0.0578 0.05 �0.0493 0.1773 1.23 0.2681Avg. diff in rates between Transferred and NTNI 0.0129 0.0331 0.05 �0.0521 0.0778 0.15 0.6976Avg. diff in rates between Prov/RHA and NTNI 0.0313 0.0687 0.05 �0.1034 0.1659 0.21 0.649Avg. diff in rates between Integrated and Transferred 0.0511 0.0573 0.05 �0.0611 0.1634 0.8 0.3718Avg. diff in rates between Integrated and Prov/RHA 0.0327 0.0827 0.05 �0.1294 0.1949 0.16 0.6923Avg. diff in rates between Transferred and Prov/RHA �0.0184 0.0688 0.05 �0.1532 0.1164 0.07 0.7891

J.G. Lavoie et al. / Social Science & Medicine xxx (2010) 1e86

been a significant trend in the rates of hospitalization for ACSC overtime as the number of years post signing agreement increases. Asshown in Table 6, our findings showed that after signing a transferagreement, the rates of hospitalization for ACSC decreases witheach following year (p ¼ 0.0002). In contrast, the slope of the ratesof hospitalization for ACSC did not significantly change as thenumber of years post signing an integrated agreement increases(p ¼ 0.3814). This result may however be due to the size of theintegrated agreement sub-sample (N ¼ 10,015) and the limitedyears that lapsed since this model was first introduced in 1996. Thissuggestion will require a replication of this study with a largersample.

Caution should be exercised in interpreting these results. Whilethe results of this study suggest that transfer was associated withimproved outcomes, the objective of closing the gap is far fromhaving been reached, as shown in Fig. 2.

Discussion

This study sought to document the relationship between localaccess to primary health care, measures of community control andthe rates of hospitalization for ACSC in First Nations living on-reserve, in the province of Manitoba, Canada. We acknowledgea number of limitations to this study. First, we used locality (postalcodes) as opposed to ethnicity to identify First Nations. As a result,it is likely that some non-indigenous individuals living on-reserve(employees, partners), and some First Nations and non-indigenousindividuals living close to the reserve, were included in the sample.Since this study is focused on the impact of local access to care, wesee this broader inclusion as acceptable. Many of these communi-ties are remote and relatively isolated. Further, it is generally thecase that First Nations living close to a reserve will seek care on-reserve. Since access to care is constrained by geography, it isreasonable to assume that barriers to access care are shared bythose who live at proximity to the reserve. A second limitation isrelated to the size of our sample, and of communities, which pre-vented us from undertaking condition-specifc analyses. Suchanalyses would have allowed us to look for condition-specificresponse time, as well as condition-specific service gaps. We arecurrently pursuing discussions in order to replicate this study inother provinces. While this may provide opportunities to increaseour sample size, it will also create challenges related to data

Table 6Relationship between models of community control over time and hospitalizationrates for ACSC.

DF Chi-Square Pr > Chi Sq

All conditions Transfer and integrated 1 11.99 0.0005Acute conditions only Transfer and integrated 1 0.72 0.3966Chronic conditions only Transfer and integrated 1 10.6 0.0011Vaccine preventable

conditions onlyTransfer and integrated 1 9.95 0.0016

All conditions Transfer only 1 14.25 0.0002All conditions Integrated model only 1 0.77 0.3814

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comparability. A third limitation is that, following Caminal,Starfield, Sanchez, Casanova, and Morales (2004), we opted todevelop our own definition of ACSC, to match the epidemiologicalprofile of First Nations. This choice will limit the comparability ofour results to other studies. While this is a limitation, our purposewas to document the impact of a policy option on health outcomes,to complement other studies that compared the prevalence ofhealth conditions, and the disporportionate rates of avoidablehospitalization among Manitoba First Nations, Canadian andManitoba population (Martens et al., 2002, 2005; Martens, Martin,O’Neil, & MacKinnon, 2007). The final major limitation is the factthat this study is observational, and as such our results are asso-ciations. Causation cannot be assumed. That being said, the dataused for this study include all people living on First Nationscommunities. Further, this comparative time trend analysis withrural Manitoba being a comparison group demonstrates a dramaticchange in ACSC hospitalization rates in the First Nations commu-nities compared to a much smaller change in the rural communi-ties’ comparison group. Still, we acknowledge that communities arediverse, and that other factors may have influenced our results.

Our study documented two key findings. First, we found thatcommunities with better access to primary health care at thecommunity level (nursing stations) had lower rates of avoidablehospitalization for ACSC. Conversely, communities with morelimited access to primary health care services at the communitylevel showed higher rates of hospitalization. As a result, 37 of the 59communities in our sample (60 percent of First Nations in oursample) have limited access to primary health care services at thecommunity level and higher rates of avoidable hospitalizations forACSC. These findings echo those reported by Martens et al. (2002),and suggest that the current framework adopted by FNIHB forfunding health services on-reserve is not meeting needs. Thereasons are likely many. To begin, communities that have no accessto services locally are located close to a provincial point of services(general practitioner or hospital). Most First Nation communitieshowever have limited to no access to public transportation. Whilethe federal government provides a transportation subsidy to thosewho must travel to access care off-reserve (Health Canada (FNIHB),2005), this budget is constantly strained by demands, and delays inapproval as well as cut backs have been reported. Although thisfactor applies to all communities, communities with no or limitedlocal access to care may be particularly disadvantaged.

Further, research continues to show that tacit and sometimesovert discriminatory practices and policies continue to marginalizemany First Nations in the mainstream health care system (Browne,2005, 2007; Kaufert & O’Neil, 2004; Smith, Varcoe, & Edwards,2005; Smith, Edwards, Varcoe, Martens, & Davies, 2006; Stout,Kipling, & Stout, 2001; Varcoe & Dick, 2007). In part, negativehealth care experiences stem from encounters with health careproviders who may be relating to First Nation patients on the basisof stereotypes or misinformed assumptions. Reports of FirstNations responding by delaying or refusing to seek care outside thereserve have been documented (Lavoie, Forget, Rowe, & Dahl,2008).

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Fig. 2. Rates of hospitalization for ACSC over time.

J.G. Lavoie et al. / Social Science & Medicine xxx (2010) 1e8 7

Still, these results suggest that access to primary health careprovided by nurses working with an expanded scope of practicecan be effective in meeting community health care needs. This isa significant addition to the literature, which tends to focus onaccess to primary care delivered by general practitioners (Starfieldet al., 2005). Our findings suggest an alternative for communitieswhere local access to general practitioners is constrained bydiseconomies of scale.

Our results also suggest that the current complement ofservices is insufficient to close the gap, and that expanding thecomplement of services available on-reserve in communitiesserved by a health office or a health centre may result in a reduc-tion in avoidable hospitalization for ACSC and in savings forManitoba. It is worthy to note that FNIHB’s policy to onlycomplement services presumed accessible provincially has a directimpact on provincial health expenditures. Our results question theoverall efficiency of the health care system, which spans federaland provincial jurisdictions, as long as policy decisions maycontinue to be made by one party while ignoring the impact on theother. This finding has implications for the various tripartitenegotiations underway in Manitoba and elsewhere in Canada,where provincial governments are working with First Nations andfederal authorities to establish partnerships for health care serviceadministration.

Second, the results of our study show that communities thatentered into a transfer agreement showed better outcomes: thelonger in a transfer agreement, the better the outcomes. Althoughwe expected to see a two to five year delay between the signatureof an agreement and improvements in outcomes, our findingsinstead show improvements within the first year and thereafter.Interviews conducted in the context of the Evaluation of theHealth Transfer Policy (Lavoie et al., 2005) suggest some possibleexplanations. To begin, many communities retained at least someof their health care staff after Transfer, thereby ensuring conti-nuity. Further, Transfer occurs after a period of 21 months ofplanning, where the community is expected to undertakea community-based assessment and develop a local health careplan. Once the agreement is signed, this plan is implemented.This process may be key in ensuring that gains can be achievedsoon after Transfer.

At the national level, this study is a first attempt at quantifyinghealth outcomes evidence in relationship to policies adopted byFNIHB. Our results are encouraging: the last two decades haveresulted in improved outcomes. Internationally, our findings arealso significant. Over the past decades, several advocacy and policypapers have mentioned Indigenous self-determination as one keypathway to closing the gap between the health of Indigenouspeoples and that of their national counterparts (Reading et al.,

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2007; Reading & Nowgesic, 2002; United Nations, 2007). Gover-nance has been cited as perhaps themost important determinant ofFirst Nation community health in recent publications by the WHOon the Social Determinants of World Health OrganisationCommission on Social Determinants of Health (2008) and the BCProvincial Health Officer’s Report (2009). First Nation leaders andelders have long articulated the view that self-government isfundamentally linked to improved community well-being. Similarclaims have been made by Aboriginal and Torres Strait Islanders inAustralia (Anderson et al., 2006), and among the M�aori of NewZealand (Durie, 1998, 2001). Although a link between self-deter-mination and outcomes has been suggested (Chandler & Lalonde,1998), our study is the first to show a correlation. It therefore fillsan important gap in the literature, both in OECD and LMIC countries(Liu, Hotchkiss, & Bose, 2008).

Finally, on September 13th 2008, The Lancet marked the 30thanniversary of the Alma-Ata Declaration (World HealthOrganisation & UNICEF, 1978) by publishing eight papers whichaimed to revisit, update, and relaunch the keymessages from Alma-Ata (A renaissance, 2008). We are pleased to contribute evidence tothe statement,

The mobilization of groups and communities to address whatthey consider to be their most important health problems andhealth-related inequalities is a necessary complement to themore technocratic and top-down approach to assessing socialinequalities and determining priorities for action (World HealthOrganisation, 2008, p. 36).

We hope that the international community will consider ourfindings when rethinking primary health care, especially for pop-ulations living in marginalizing circumstances.

Acknowledgements

The authors would like to acknowledge the participation of theAssembly of Manitoba Chiefs in the planning of this study, and theChiefs Task Force for their assistance in the analysis of the data.We would also like to acknowledge the Canadian Institutes forHealth Research and Manitoba Health who provided the financialsupport for this study. We are thankful for the assistance providedby the Manitoba First Nations Centre for Aboriginal HealthResearch and the Manitoba Centre for Health Policy, University ofManitoba. Patricia J. Martens would like to acknowledge theCanadian Institutes of Health Research (CIHR) and the PublicHealth Agency of Canada (PHAC) for her CIHR/PHAC AppliedPublic Health Chair (2008e2013). Finally, we would like to thankthe anonymous reviewers for their very insightful comments onan earlier draft.

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J.G. Lavoie et al. / Social Science & Medicine xxx (2010) 1e88

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