Residents of remote communities in Canada’s three northern territories experience substantial health disparities and do not have the same access to health care as Canadians living in urban centres.
Northern Canada’s widely scattered small communities cannot rely on physicians, whether resident or visiting.
Technological innovations, appropriate training, better coordination and communication, adoption of culturally based healing systems and development of environmentally sustainable communities may help to address challenges.
However, moving beyond “primary care” as services provided by physicians and other providers to the more comprehensive, upstream and multisectoral concept of “primary health care,” which is well aligned with Indigenous values and concepts of wellness, is critically important to advance health equity.
Primary care has featured prominently in national debates on what ails the Canadian health care system and what holds the key to its sustainability. Most jurisdictions in Canada have attempted primary care reform in recent years,1 but reference to Northern Canada is conspicuously absent from the plethora of critiques and analyses. Primary care would be enhanced in Canada’s northern and remote communities through incorporation of the values and knowledge of local and Indigenous peoples into system planning.
Canadians in remote communities, particularly in the three northern territories, do not have the same access to health care as Canadians living in urban centres in the provinces. Surveys have shown that in terms of the proportion of the population who have a regular doctor, northerners are worse off than other Canadians, with patients in Nunavut experiencing the largest disparity.2 However, primary care in Northern Canada is about more than services provided by family physicians. There are actually two primary care models in Northern Canada, one that exists within its regional centres and capital cities, with family physicians as the entry point, and another in remote communities, with nurses as the entry point. Most Indigenous people live in the remote communities, whereas non-Indigenous people live mainly in cities. The nurse-based system of primary care in remote northern communities is supported by periodic physician visits and depends on community health representatives, electronic health records, consultation services, and a telecommunication and transportation system that links these health centres with regional hospitals and facilities in southern Canada. The nurse-based system ensures round-the-clock access to a primary care provider in remote communities.3 Given the large number of small communities scattered over an enormous land mass, primary care in these communities can never rely on physicians, whether resident or visiting. Task shifting (the redistribution of tasks among different categories of providers), which is a strategy used globally to meet the primary health care needs of underserved populations,4 has been in place in Northern Canada for decades. However, little attention has been paid to assessing the performance of the task-shifting model of primary care in the Canadian context.
There are many challenges to ensuring access to primary care in northern communities. A recent review of health care in Nunavut by the Auditor General of Canada5 found staff turnover to be an intractable problem, alongside difficulties in recruitment and retention. However, a recent conference focusing on remote health care identified several promising innovations.6 These included use of remote presence technology in providing physician services from a distance and in the training of primary care providers closer to home; land-based training of community paramedics and wider dissemination of self-care skills; centralization of the emergency evacuation response and clinical support system; development of healing models that incorporate Indigenous values and are connected to the land; mutually respectful communication between the frontline and regional centres; and culturally responsive and environmentally sustainable architectural design of homes and communities that promote healing and wellness.
Although different systems of care may ensure access to a health care provider, health disparities continue to exist between Indigenous and non-Indigenous populations in Northern Canada.2 Improvements in the health care system can be made at the level of personnel and technology, but there is a need to move beyond the narrow definition of primary care as provision of services by family physicians, nurse practitioners and other providers, and address the more comprehensive concept of primary health care by developing upstream and multisectoral policies to advance health. As originally framed in the landmark Declaration of Alma Ata on primary health care in 1978,7 all people have a right to health, and communities should be encouraged to participate in the planning, organization, operation and control of primary health care in the spirit of self-reliance and self-determination. The principles of Alma Ata are well aligned with Indigenous values and holistic conceptions of wellness in Northern Canada. Canadian Inuit, First Nations and Metis fully recognize the importance of the social determinants of health and have expanded the concept to include culture, language, balance, life control, education, material resources, social resources and environmental connection.8,9
Over a decade ago, the Royal Commission on Aboriginal Peoples called for Indigenous control of the institutional systems that affect their health,10 a proposal endorsed by national Indigenous organizations such as the Inuit Tapiriit Kanatami and the Assembly of First Nations. Recent developments in the First Nations Health Authority in British Columbia offer a model for other province- and territory-wide health systems controlled by Indigenous communities and organizations, incorporating traditional knowledge and culturally based healing systems. While land claims settlements and political self-determination have advanced in the three northern territories, there is still a need for higher levels of engagement with Indigenous governments and communities on health services planning and delivery.
In Canada’s northern territories, frequently observed health disparities call for an urgent reframing of the goals and systems parameters of primary care reform. Although currently available data suggest that the current system may have served the basic needs of patients in terms of health care access, in-depth analyses of the performance of the primary care system are still lacking.
Primary care providers are gatekeepers to the health care system in Northern Canada. Even though they are challenged with the immediate demands of acute care, they must ally with Indigenous leaders to support primary care reform in partnership with patient (i.e., community) representatives who understand the causes of inequality and have personally experienced their consequences. Development of innovative solutions that can bring about broad system change to advance health equity in Northern Canada depends on their willingness to form such an alliance.
Footnotes
Competing interests: None declared.
This article has been peer reviewed.
Contributors: Both of the authors contributed substantially to the conception and design of the article. Kue Young drafted the article and Susan Chatwood revised it critically for important intellectual content. Both of the authors gave final approval of the version to be published and agreed to act as guarantors of the work.
Funding: This commentary is based on research supported by a Canadian Institutes of Health Research team grant in Community-Based Primary Health Care (TT6-128271).