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When First Nations establish health management structures, they first need to determine mandates and authorities for providing health care services for one or more communities. Chiefs and councils mandate First Nations health management structures through band council resolutions or other forms of approval appropriate to First Nations. These mandates cover planning, organizing and providing health care services to community members. Community health plans describe these services and become the operating guidelines for First Nations health management structures. These health management structures are the essential components of community health care initiatives.
Members or directors of First Nations health management structures need to have high levels of community commitment. These community members are responsible for ensuring that health management structures operate legally, that services are effective and that finances are wisely administered.
Understanding the Canadian health care system will assist First Nations to create efficient health management structures. Although the Community Health Plan sets out health management structure operating guidelines, understanding how to support the Plan within the context of the Canadian health care system is important.
The Constitutional Act of 1867 assigned various responsibilities to the federal and provincial governments, including health care, education and social services. Recently, two other important players have entered the health care sector--First Nations and other non-governmental organizations, and municipalities. The relationship among these governing partners is continually evolving as they redefine shared responsibilities. Establishing First Nations health management structures is another development in this relationship.
Integration and harmony throughout the complete spectrum of health programs and services are important for First Nations communities. This integration reflects Aboriginal people's concepts of health and well-being (holism), which are similar to a wellness model based on broad determinants of health. Ideally, holism means that social and health services should be integrated.
At the very least, health and health-related services should be coordinated in a holistic manner which respects physical, mental, emotional and spiritual outcomes. When First Nations communities design health systems, they need to integrate health and health-related services that are holistic and compatible with their goal of self-determination.
The Canadian health care system comprises several specialized, interrelated elements. Federal, provincial and municipal governments manage many of these elements. First Nations and non-governmental organizations are responsible for managing other elements. First Nations health management structures have an important role to play in adapting health service delivery to the specific needs of their communities.
Members of First Nations health management structures can examine the range of services managed by other jurisdictions when planning comprehensive community-based health care systems. The range of services needs to include appropriate referral access for the special needs of community members.
Listed below are examples of direct health services provided by various levels of government.
A First Nations health management structure may be either a health committee or a health board/authority. A committee is not incorporated, but a health board/authority is incorporated under provincial or federal laws, or both. Either type of health management structure may employ a Health Coordinator/Director.
The health coordinator/director manages the following day-to-day activities of the health management structure:
A First Nations health committee comprises community members appointed by chief and council who consult with the community and actively promote the delivery of appropriate health services. The health committee operates in a supportive role and is responsible for promoting community awareness of healthy lifestyles that reduce the need for medical care.
A First Nations health board/authority is a separate nonprofit legal entity authorized by means of a band council resolution. It can be incorporated under either federal or provincial laws. Once chartered, it has the power to set by-laws governing its operations, to hire and manage staff, and to make financial decisions for providing services previously provided to First Nations communities by the First Nations and Inuit Health Branch of Health Canada. This guide focuses on establishing a health board/authority.
Establishing a First Nations health board/authority presupposes that, after consultation with the community, the chief and council have decided to entrust this body with the responsibility for health care programs. The First Nations health board/authority may have authority to obtain resources needed for controlling community health care services. Developing community health by-laws establishes this authority.
Community health by-laws set out a series of guidelines, including statements on the following items:
Armed with an appropriate set of guidelines or by-laws, the First Nations health board/authority can then draft working rules for delivering community health care programs. These working rules define:
-priorities - programs -policies -procedures
Health board/authority members and directors need to represent a good cross-section of the community benefiting from health programs.
At some point early in its mandate, the First Nations health board/authority will want to write its mission statement. A mission is a statement of intent about the overall job the health board wants to do. An example of a First Nations health board mission statement is the following:
The mission of the First Nations Health Board of Musquodobit is to assist First Nations people to achieve physical, mental, emotional and spiritual well-being through the provision of culturally appropriate health promotion, disease prevention activities and health services.
The following chart is a typical health board/authority management
structure for delivering community health services in First Nations
Chief and Council
First Nations Health Board
Board of Directors
First Nations Health Board
Technical Support Staff
The professional and paraprofessional personnel who work for the health board/authority are responsible for delivering the health care services the community expects to receive under the Community Health Plan.
After a community establishes a First Nations health board/authority with defined mandate and authority, the health board/authority defines its duties and responsibilities. Some of these duties and responsibilities are highlighted below.
Following the objectives and priorities of the Community Health Plan, the First Nations health board/authority establishes policy directions reflecting the community's philosophy and goals. Also, it reviews its policies with the community at large once a year when it presents its annual program report on health care services.
The First Nations health board/authority ensures that health care programs address the community's needs and priorities. As circumstances or requirements change, the programs need to be flexible enough to modify easily.
The First Nations health board/authority sets out personnel policies and establishes and applies procedures. It oversees the development of management and administrative practices. Also, it must ensure that its personnel follow procedures developed from policies. Finally, it must establish maintenance standards for its premises.
All community activities are sustained with the ongoing consent of the members of the community. The First Nations health board/authority is no exception. Although the chief and council create the board by a formal act, the board must follow the community's guidance in matters of health. This obligation is carried out through a process approved by chief and council that reinforces their authority to speak for all community members while being accountable to them.
Transfer agreements require that First Nations communities give their members annual reports within 90 days of the end of each fiscal year. The annual report, based on the Community Health Plan, contains the following information:
The chief and council are accountable to the Minister for meeting the terms and conditions of the transfer agreement. Transfer agreements require that First Nations communities give the Minister the following reports within 90 days of the end of each fiscal year:
The First Nations health board/authority establishes standards of performance for personnel, management practices and service delivery. The health board/authority reviews individual staff performance based on these standards. Also, it is responsible for staff development. Staff participation in continuing education courses, workshops and training sessions helps them to update and improve their skills. Professional staff must keep current with advances in their disciplines by attending professional continuing education workshops, seminars and conferences.
The First Nations health board/authority is responsible for approving the annual budget based on community health care priorities and for ensuring that expenditures are kept within budget. Its responsibilities include ensuring that funding arrangements with governmental and non-governmental agencies are in place and that funds are received on time.
Community involvement ensures that the community-based health care delivery system meets the needs of community members and provides for evaluation of community health programs. Community involvement provides a collective voice that shapes the health care delivery system by involving members in various processes leading to decision-making. Effective two-way communication ensures that community members are aware of health board/authority activities and encourages members to make suggestions to the health board/authority. These suggestions show that communication between the health board/authority and the community is working effectively. Health board members need to inform community members about success in addressing health problems and to inform them about continuing problems. Success stories assure everyone that progress is taking place and encourage community involvement in addressing health challenges.
To ensure accessibility to all available health care programs and sponsorships, the First Nations health board/authority needs to develop the best possible working relationships with appropriate federal, provincial, municipal and private agencies. In these contexts, the Community Health Plan becomes the most effective means of identifying how to meet community needs.
When a First Nations health board/authority plans and directs community health programs, it requires liability insurance. A First Nations health board/authority is legally responsible for its own actions and for the actions of those employed in the health program. It is responsible for all members of the community health care team, including the following members:
Health care staff members need liability insurance to cover them while performing their duties and for accidents and mishaps on the premises where they provide health programs. Usually, this coverage is provided through the First Nation health organization.
For professional health care staff, personal liability and malpractice insurance coverage may be available through their professional associations. In any case, the First Nations health board/authority must ensure that all professional contract staff members are registered or licensed with provincial professional regulating authorities and have malpractice insurance. Because the First Nations health board/authority may also be held liable for something a contract employee does that harms someone, the board/authority must carry liability insurance that covers contract employees and full-time, permanent employees.
The First Nations health board/authority may wish to join provincial hospital or health care associations and secure liability insurance through these organizations. This type of membership broadens the health board/authority's network of health care organizations.
Should this type of membership not be available, the First Nations health board/authority needs to review coverage options directly with insurance brokers and companies. Obtaining quotations from several companies before deciding upon the final contract is advisable.
The First Nations health board/authority is the implementor of the community's plan for current health care needs and for the timely development of improved health service as circumstances change.