PART V. CONCLUSION

While community control and self-determination have improved the delivery of health care in Indigenous communities, efforts to establish these have not yet been sufficient to close the gap in health disparities between Indigenous and nonIndigenous populations (Kelly, 2011). This is due, in part, to the deeper structural issues Indigenous communities face and the lack of control they have over major determinants of health, such as access to food, water, and housing (Levesque, 2017). Self-determination over health programs and services has led to improved access to health and prevention services for Indigenous people and communities, as well as to some promising improvements in health outcomes, including lower rates of hospitalizations for conditions that are treatable at the community level, improved mental health, and reduced otitis media, among others (AFN, 2017; Sabbioni et al., 2018; Sibthorpe et al., 2017). However, self-determination requires that communities have the tools and resources they need to deliver high-quality programs and services that address their needs and priorities. The literature highlights the importance of flexible and sustainable funding models, a strong sense of community ownership, strong governance structures and accountability mechanisms, strong partnerships at all levels, and opportunities to link with other sectors to affect the determinants of health and strengthen Indigenous capacity for self-governance (AFNHP, 2016; Lavoie & Dwyer, 2016). These types of arrangements are critical for encouraging innovation in health services delivery. Given the challenges associated with current funding arrangements, capacity must be strengthened within Indigenous communities to enable them to take control over their own programs and services.

Provincial, territorial, and federal governments must work as equal partners with Indigenous Peoples and communities to determine the governance and funding models that will work best in meeting their unique and diverse needs and priorities. All levels of government must be committed to and support, through policy and adequate resources, the development of Indigenousdriven health programs and services, regardless of whether these serve urban Indigenous populations or Indigenous Peoples who have signed selfgovernment agreements.

Within the scope of this literature review, the evidence does not lead us to conclude that there is one particular model of best practice in Indigenous health governance. While one model may be promising, Indigenous Nations across the country are unique and distinct, and therefore need to be creative in designing a control model that works for them. Indigenous communities need to be able to identify their own priorities and address their own unique needs, utilizing approaches that reflect their own worldviews and community contexts. They must not be expected to transpose an existing healthcare model into their individual and collective contexts. Although most models include partnerships between Indigenous and various levels of non-Indigenous governments, the multi-jurisdictional context of Indigenous Nations in Canada will require Indigenous Services Canada, in partnership with First Nations, Inuit, and Métis Peoples and communities, to be creative in co-designing a control model that works for them, based on underlying Indigenous Knowledges and the unique histories and conditions that contribute to success.

Results of the review found that although there is no one overarching model for successfully devolving federal healthcare services to Indigenous communities, some common features are shared by models of Indigenous health governance, both internationally and domestically, that support Indigenous self-determination and aim to improve health outcomes for Indigenous Peoples.

These include the following:

Sustained national government commitment to Indigenous rights and selfdetermination Clearly articulated roles and responsibilities between federal, provincial/territorial, and Indigenous governments in health governance Scalable self-determination dependent on capacity Community engagement and participation in the design and delivery of health programs, services and policies, both locally and within the health system at large Health programs and services grounded in Indigenous ways of knowing, worldviews, and perspectives Strengths-based holistic approaches to health programs and services Citizenship defined by Indigenous communities as a foundation for both positive relationships with governments and a stronger sense of self-determination Adequate, sustainable, and flexible funding arrangements that can be linked directly to local needs and adapted to meet emerging priorities, and that can facilitate longterm planning and integrated, multidisciplinary approaches Representative Indigenous non-profit governance structure Collaborative and shared leadership, based on true partnership Harmonized contractual and accountability requirements Strong partnerships and collaborations with other stakeholders with an interest in Indigenous health to leverage expertise and service delivery capacity Strong two-way relational accountability Involvement in data collection/management to inform program design and policy development Involvement in workforce development to promote recruitment and retention, as well as a well-trained, culturally sensitive workforce Quality assurance processes based on cultural outcomes and indicators, utilizing community owned and led approaches Ongoing federal/provincial/ territorial government support for Indigenous health governance in the way of human, physical, and financial resources.