Restructuring First Nations Health Governance: A Multilevel Solution to a Multifaceted Problem

This paper investigates current health governance structures as a contributing factor to the disproportionate burden of ill-health and inequitable health service delivery experienced by First Nations communities. A review of the contemporary and historical context sets the stage for the analysis, outlining health status, social determinants of health and the policy framework within which health inequities are situated. The paper proceeds with a critical analysis of power imbalances perpetuated within Canada’s health care system in the form of barriers such as inadequate health services, fragmented governance, jurisdictional gaps and lack of government accountability. The discussion explores selfdetermination as a means of empowering First Nations communities to take control of the design, delivery and evaluation of health care services and ultimately, reclaim control of their health and wellbeing. Four models of self-government are evaluated to highlight several key features of a sustainable framework, including: recognition of autonomy, a voluntary process, an opt-in/opt-out provision, protection by legislation and the support of a fiduciary relationship with the State. Finally, a multilevel mosaic model of self-government is proposed as a pragmatic framework that is adaptable to the varying needs and capacities of First Nations communities.