INTRODUCTION

It is well documented that Indigenous Peoples 1 around the world experience poorer health status in comparison to non-Indigenous populations. There is a considerable body of international evidence that shows these health disparities are linked to complex interactions between historical and contemporary structural, social, political, economic, and environmental factors that influence populations across their life span, referred to as the social determinants of health (George, Mackean, Baum, & Fisher, 2019; Jackson Pulver, Waldon, & Harris, 2015; Jones et al., 2019; Lines & Jardine, 2019; Reading & Wien 2013). As far as they affect Indigenous Peoples, these disparities have proven to be deep, enduring, and resistant to government efforts to address them (Angell, 2017). While there have been a number of global achievements related to improving population health, the continued poorer health status of Indigenous Peoples around the world illustrates the impact of systematic, socially produced, and unfair policies and practices on the presence of disease, health outcomes, and access to health care (Anderson et al., 2016; Kirmayer, & Brass, 2016).

Indigenous Peoples have long advocated for the right and responsibility to design, deliver, manage, and, ultimately, control their own health programs and services, which many believe is key to closing existing gaps in health outcomes between Indigenous and non-Indigenous populations (Assembly of First Nations [AFN], 2017; Australian Government, 2015; Gottlieb, 2013; Harfield, Davy, McArthur, Munn, & Brown, 2018). Selfdetermination is one of the most important determinants of Indigenous health and wellbeing (Reading & Wien, 2013). It is considered essential for empowering and enabling communities to build capacity and gain control over the wideranging forces that affect health and well-being at individual and collective levels (Garces-Ozanne, Ikechi Kalu, & Audas, 2016). While social determinants of Indigenous health and Indigenous rights to self-determination “may be acknowledged in policy rhetoric, … they are not always a priority for action within policy implementation” (George et al., 2019, p. 1). To achieve equitable outcomes, Indigenous Peoples must be given full access to high-quality, responsive, comprehensive, culturallyrelevant, and coordinated health and social services that target the diverse determinants of health, including individual and community self-determination (AFN, 2017; Greenwood, 2019; Jones et al., 2019). In recognition of this, governments in Canada and internationally have committed to health systems reform to address health inequities and determinants of Indigenous health, support Indigenous self-determination, and influence better health outcomes for Indigenous Peoples (Alberta Health Services, 2018;

1 The term “Indigenous Peoples” is used throughout this paper to refer collectively to the original or earliest inhabitants of a region, within Canada and internationally, as opposed to people who moved for the purposes of settling, occupying or colonizing these areas. In Canada, the term Indigenous Peoples is used to refer collectively to First Nations, Inuit, and Métis Peoples, as defined under Section 35 of the Canadian Constitution of 1982. When referring to a specific Indigenous group, the specific terms (First Nations, Inuit, and Métis) will be used.

AFN, 2017; Atlantic First Nations Health Partnership [AFNHP], 2016; Australian Government, 2015; Gottlieb, 2013; Jackson Pulver et al., 2010; Jones et al., 2019).

This paper provides a targeted review of the literature on various models of Indigenous health governance between 2000 and 2019. The purpose is to inform Indigenous Services Canada’s (ISC) work to create new health governance structures and funding models in Canada. The ISC is tasked with closing socioeconomic gaps and advancing self-determination, in partnership with First Nations, Inuit, and Métis Peoples (ISC, 2019a). Part of the federal department’s plan includes improving access to primary health care and social services for Indigenous Peoples and advancing the transformation of health services toward greater ownership, control, and management by Indigenous Nations. Accordingly, the Department is exploring options for creating new health governance structures and funding models for Indigenous communities to support the devolution of services and selfdetermination. The literature review is limited to Canada, Australia, Aotearoa (New Zealand), and the United States. The review provides strong evidence that no one model of health governance exists for all communities. Models must be desgined by the communities themselves to fit their unique needs.

This report is organized into four substantive parts.

Part 1 describes the methods used to identify relevant literature and extract information. Part 2 provides an overview of the factors that affect Indigenous health and the context of Indigenous health governance in Canada. Part 3 describes examples of health governance structures and funding models currently in place in Indigenous contexts globally and nationally. Finally, Part 4 synthesizes key findings and lessons learned from existing examples of health governance structures and funding models.