A look at the relationship between indigenous peoples and the healthcare systems. Ways to improve and change these relationships. Peer-Reviewed Article

1. ORIGINAL ARTICLE
Modelling change and cultural safety:
A case study in northern British Columbia
health system transformation
Margo Greenwood1
Abstract
The relationship that Indigenous Peoples have to the Canadian healthcare system makes the system’s weaknesses and
complexities obvious. The long-standing lack of consideration to the historical and contemporary realities of Indigenous
Peoples has resulted in miscommunication, misunderstanding, mistrust and racism. Health leaders, including health authorities,
across the province are thus challenged to ensure that culturally safe environments are available and culturally safe practices are
being used. This article begins with an overview of contemporary social political contexts in which Indigenous individual and
collective realities are situated. Following is a conceptual discussion focused on health system change and the experiences of
Indigenous Peoples. Change at structural, systemic and individual levels is the focus of the change model presented in this article.
Throughout this exploration, examples of concrete actions currently underway in a health authority are offered. The article
concludes with visions for future change.
Introduction
The relationship that Indigenous Peoples have to the Canadian
healthcare system makes the system’s weaknesses and com-
plexities obvious. The long-standing lack of consideration to
the historical and contemporary realities of Indigenous Peo-
ples has resulted in miscommunication, misunderstanding,
mistrust and racism. Health leaders, including health author-
ities, across the province are thus challenged to ensure that
culturally safe environments are available and culturally safe
practices are being used. This article takes the position that
structural, systemic, and service delivery dysfunction in the
mainstream healthcare system for Indigenous Peoples in
Canada requires transformation at structural, systemic, and
service delivery levels—an approach that is modelled in
Figure 1.
The good news is that this transformation has already begun
to take shape in many jurisdictions, with Indigenous organi-
zations and individuals leading the way. In British Columbia,
for example, health authorities across the province have been
challenged to ensure culturally safe environments and prac-
tices, and in 2017, the province released its Declaration of
Cultural Safety and Humility (2017), which speaks directly to
culturally safe practice as a way to address anti-Indigenous
racism in healthcare systems. As an Indigenous scholar and
Vice-President of Indigenous Health in British Columbia’s
northernmost health authority, Northern Health (NH), I write
this article based on personal and professional experiences of
implementing actions designed to create and support culturally
safe practices and environments in British Columbia. I
acknowledge and am grateful to NH and to the First Nations
Health Authority (FNHA) for this opportunity. The article
begins with an overview of the contemporary socio-political
context in which Indigenous individual and collective realities
are situated in Canada. This is followed by a conceptual
discussion of healthcare system change at structural, systemic,
and service levels and the experiences of NH.
Throughout this exploration, I offer examples of concrete
actions currently underway in a health authority that is seeking
to create a healthcare delivery system that is experienced as
culturally safe by the many diverse Indigenous individuals,
families, and communities we serve. Humility in recognizing
that there is a different, better way to do things and that the best
knowledge about health is rooted in thriving communities
underpins the transformations underway at all three levels of
change explored here: service, systemic, and structural.
Background: A time of opportunity
One could argue that in the present historical moment, Indi-
genous Peoples have greater opportunities for change than ever
before. This change has been a long time in coming, and there
is still far to go, but in 1996 the Royal Commission on
Aboriginal Peoples (RCAP) envisioned a “circle of wellbeing”
in which self-government, economic self-reliance, partnerships
of mutual respect with Canada, and healing would feed into one
another. Together, each and all of these elements of reconci-
liation would work toward elimination of persistent inequities.
While too few of RCAP’s recommendations were implemented
in the decades following the conclusions of the commission, it
nonetheless became the impetus for a thorough examination of
residential school experiences of Indigenous Peoples through
the Truth and Reconciliation Commission (TRC; 2008-2015).
1
National Collaborating Centre for Aboriginal Health, Prince George, British
Columbia, Canada.
Corresponding author:
Margo Greenwood, National Collaborating Centre for Aboriginal Health,
Prince George, British Columbia, Canada.
E-mail: margo.greenwood@unbc.ca
Healthcare Management Forum
2019, Vol. 32(1) 11-14
ª 2018 The Canadian College of
Health Leaders. All rights reserved.
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0840470418807948
journals.sagepub.com/home/hmf

2. The TRC final report, released in 2015, offers 94 Calls to
Action to redress the legacy of residential schools and to
advance the process of Canadian reconciliation. The transfor-
mative change actions described in this article are anchored in
these Calls to Action (particularly Actions 18 to 24), alongside
a moral imperative that is long past due.
The opportunity for change presented by the conclusion of
the TRC coincided with the election of a new Federal Gov-
ernment in 2015. Under the leadership of Justin Trudeau, the
Liberal government committed to “a renewed nation-to-nation
relationship with Indigenous Peoples based on recognition,
rights, respect, co-operation, and partnership.”1
Now three
years into Liberal leadership, contentious politics regarding
pipelines and other territorial issues have called this commit-
ment into question by many, but at the same time promising
movements from both within and outside government are
seeking to hold the Canadian establishment to account for their
actions and non-actions impacting Indigenous rights, health,
and wellbeing. One of the government’s first steps in addres-
sing renewed Indigenous relationships in 2016 came in the full
endorsement of the United Nations Declaration on the Rights of
Indigenous Peoples, which up until then had only conditional
support from the Federal Government. Ruling in an ongoing
legal struggle for equity in funding for services for Indigenous
children, the Human Rights Tribunal found in 2016 that the
Government of Canada discriminates against First Nations
children on reserves by failing to provide the same level of
child welfare services that exist elsewhere, highlighting
decades of injustice and disadvantage. Children of the “Sixties
Scoop” are just starting litigation, while patients of Indian
hospitals are also beginning to come forward. These are all
painful, yet necessary and promising steps toward reconcilia-
tion. This action between Canada and Indigenous Peoples will
not happen quickly or without great tension and emotion—yet
we begin. The next sections describe some of the steps taken
toward transforming health systems and service delivery in
British Columbia, as we seek a way forward to healing and
renewed relationships within the healthcare system, presenting
at the same time a model to help conceptualize these changes.
A framework for getting to change:
Conceptualizing new relationships in health
It is one thing to conceptualize what types of changes must
occur to create a healthcare system that is safe and effective for
Indigenous Peoples, and it is quite another to consider how
those changes can happen on the ground. This section presents
a “change model” (Figure 1) depicting the three interconnected
layers or strata in which change must occur for genuine
transformation in the healthcare sector (structural change,
system change, and service delivery change) and uses examples
from British Columbia, Canada, to illustrate these changes in
action. Although these changes are still relatively new and
implementation is ongoing, they provide a useful grounding in
the ways a complex process of transformation is unfolding in
one corner of the colonized world.
Change in the sector of Indigenous health is complex and
multi-faceted because Indigenous health is complex and multi-
faceted. In order for genuine and lasting transformation in the
health of Indigenous Peoples, policy actions must cross diverse
sectors and disciplines and have to occur across multiple levels.
Social Determinants of Health (SDOH) approaches point to
wholistic ways to address the health inequities experienced by
Indigenous Peoples, and Canadians have been at the forefront
of understanding and developing SDOH. The Ottawa Charter
for Health Promotion declared in 1986 that health is “created
and lived by people within the settings of their everyday life,
where they learn, work, play, and love.”2
More than a decade
later in 1998, Health Canada developed a comprehensive list of
factors influencing health, labelling them the determinants of
health. The release of the World Health Organization’s Com-
mission on the SDOH’s final report, Closing the Gap in a
Generation (2009), argued for the need to address inequities
that affect some people more than others. By identifying and
focusing on the causes underlying the causes of ill health—for
example, high tuberculosis rates associated with overcrowding
and housing shortages linked to poverty and forced reloca-
tion—SDOH approaches require attention to the unique his-
torical and contemporary social political contexts which shape
the health of Indigenous Peoples. These include, among other
determinants, considering things like social environments,
physical environments, personal health practices and coping
skills, healthy child development, biology and genetic
endowment, health services, and gender and culture. Indigen-
ous Peoples have expanded upon these determinants, arguing
that factors such as land, spirituality, colonization, culture,
language, and self-determination are all important aspects of
health and wellbeing.3
Indigenous models of determinants of health, like those
offered by Reading et al.,4
Greenwood,5
and Reading and
Figure 1. A framework for creating change.
12 Healthcare Management Forum

3. Wein,6
all consider (in addition to the wholistic interrelated
nature of the determinants) a life course perspective, and the
necessity for multi-level, cross-disciplinary implementation
strategies of policies meant to ameliorate inequity. The Change
Framework presented in Figure 1 is anchored in these broad
principles and offers a deceptively simple structure with three
overarching and interrelated categories in which to take action
for change. The change model merges these broad determi-
nants of health principles with tenets borrowed from Bron-
fenbrenner’s7
ecological systems model to offer a seemingly
simple structure with three overarching categories in which to
take action for change. The model also has the flexibility to
take into account the “causes of the causes of the causes” in its
operational strategies and actions.
Aligning simultaneous actions across all three levels
(structural, systemic, service delivery) is necessary for long-
term and successful change. Structural change forms the outer
layer of the model, referring to high-level legislation, policies,
and/or formal agreements—in other words, structural enablers
of change. Structural enablers can either enable or hinder the
health and wellbeing of individuals and communities. An
example of structural enablers in the health sector in British
Columbia can be seen in the series of agreements and accords
signed by First Nations, the provincial government, and
the Federal Government detailed in Johnson et al.,8
which
culminated with the British Columbia Tripartite Framework
Agreement on First Nation Health Governance (2011). The
Framework Agreement outlined the commitment to support the
creation of the FNHA and transfer of responsibility and funding
for First Nations health from the Federal Government to the
FNHA within 2 years. Fully operational since 2013, the FNHA
has been instrumental in bringing about the system changes
discussed in the next section as regional health authorities in
British Columbia adopt innovative Indigenous-friendly prac-
tices, including the promotion of cultural safety for Indigenous
Peoples throughout health services.9
The second layer depicted in the model is systemic change.
This refers to direct services and systems, including the edu-
cation, health, child welfare, and justice systems. These sys-
tems drive schools, hospitals, mental health programs, and
early childhood programs. In British Columbia, the structural
enablers that precipitated significant changes in the way health
services for First Nations peoples are delivered include formal
agreements with the First Nations Council and the FNHA and
each of the province’s regional health authorities. In the
northern region of the province—a vast geographical region
home to some 50,000 First Nations, Métis, and Inuit people—
the Northern Health authority (Northern Health or NH), along
with the FNHA and the First Nations Health Council—
Northern Caucus, created a Northern Partnership Accord in
2012 in which they committed to create a joint health and
wellness plan. The Northern First Nations Health and Wellness
Plan is, in part, supported by working groups for each of five
(out of 16) priority areas. These groups provide a space for
representatives from NH, FNHA, and northern First Nations to
collaboratively work toward implementation of key actions in
each of the priority areas. In other words, there is a colla-
borative approach to operationalizing healthcare delivery.
Northern Health also created a senior executive position,
Vice-President of Indigenous Health, to provide leadership in
operationalizing the “new relationship” with First Nations in
northern British Columbia. In 2015, all Chief Executive Offi-
cers from British Columbia’s health authorities signed a
Declaration of Cultural Safety and Humility committing the
signatories to culturally safe service delivery for Indigenous
Peoples. These activities are examples of system enablers that
support the operationalization of service delivery changes.
Taken together, these structural and systemic changes are
interrelated and intended to support individual practice and the
experience of that practice, especially culturally safe practice.
At the centre of the model sits service delivery change. This
core of a larger integrated understanding reflects individual or
direct service delivery and is where people access and expe-
rience services more directly and acutely. At the scale of
human interaction, where people interface and interact with
each other is where the promotion of culturally respectful and
safe practice between Indigenous and non-Indigenous Peoples
becomes imperative. Northern Health is taking initial steps to
realize this commitment by providing healthcare professionals
in the health authority with education and training opportuni-
ties that will enhance their understanding and impact their
practice, including approximately 500 training seats annually
in cultural competency development offered by British
Columbia’s Provincial Health Services Authority. The demand
for this training continues to increase. Alongside this training,
the Indigenous Health team within NH created and released a
short animated video that introduces the concept of cultural
safety in an accessible way, including an overview of Indi-
genous health from early colonization to the present day. The
video is an invitation to all to participate in making health
systems more culturally safe for Indigenous Peoples. The
visual work is enhanced by a booklet and poster series
including terminology, factors contributing to a culturally safe
healthcare system, and features of culturally safe practices.
Indigenous knowledge(s) and practices reside within Indi-
genous communities, and in order to deliver culturally safe
care, health practitioners must understand and be respectful of
such knowledge in their practice. Accordingly, NH is seeking
to engage with Indigenous communities in a direct and ongoing
way through the work of eight sub-regional Aboriginal Health
Improvement Committees (AHICs). These committees are
eclectic in nature, geographically defined, and comprised of
local NH and First Nations health leadership including First
Nations Health Directors and other Indigenous organizations
and professionals. Representatives from sectors such as
education, child and family services, policing, and British
Columbia ambulance services are also welcomed. The AHIC
tables create opportunities for direct, local change through
activities and initiatives specific to the communities sitting at
the table.
Recent work undertaken by the AHICs has been guided by
the simple question: “If I was a new health practitioner coming
Greenwood 13

4. into your community, what would you like me to know about
you?” This question, paired with small amounts of annual
funding, has resulted in the development of a growing amount
of diverse and innovative culturally specific resources, activi-
ties, and events. In less than 5 years, the diversity of these
products has highlighted the Indigenous ways of knowing and
being as expressed in the distinct traditions, cultures, protocols,
and environments of each community. The resources are being
used to create safe, welcoming health service spaces, as well
as supporting the growth of knowledge, understanding, and
cultural safety among healthcare practitioners. They are also
being shared broadly throughout NH and beyond. A webinar
series hosted by the Indigenous Health team at NH provides a
platform for AHICs to offer highlights of the local cultural
resources developed by themselves.
The Indigenous Health team at NH has also developed
resources for use across the NH employee landscape and for
users of healthcare services. These resources include cultural
safety presentations delivered internally to different depart-
ments within NH (eg, finance and communications) and
externally to nursing students, clinician orientation sessions,
and hospital volunteers. Facilitated workshops and patient
journey mapping are other ways in which healthcare practi-
tioners and community members have engaged and learned
together. With the same intent of learning and respect, the
Indigenous Health team has also developed materials for users
of healthcare services. One pressing issue for many Indigenous
individuals is how to express concerns and complaints about
the services provided by the health system. The What to do with
Questions, Concerns and Complaints booklet supports Indi-
genous people to voice concerns with their healthcare experi-
ences, summarizing the steps and processes available for
individuals who have questions, concerns, or complaints about
their healthcare experience. The Sacred Spaces and Gathering
Places booklet is another example of an effort to improve the
cultural safety of direct services. This booklet informs Indi-
genous individuals of the spaces available in NH buildings and
grounds for their family and community members to gather.
Closing comment
Northern Health is a geographically vast and diverse health
authority sitting at the crossroads of innovative practice and
system change. Using the three-level model of change and NH
as an example, the interconnections between structural change,
system change, and service delivery change become more
clear. The exciting work at the community level represented by
the AHICs and the work of NH’s Indigenous Health team is
enabled by changes at the systemic level of interconnected
health organizations and agencies, which in turn are shaped
at the structural level of agreements, accords, legislation, and
policy as Indigenous and non-Indigenous partners negotiate a
way forward.
Creating a healthcare delivery system that is experienced
as culturally safe is essential to the overall system goal of
improving health outcomes for Indigenous Peoples. This is a
long and often difficult journey for healthcare organizations
such as NH—a journey where health leaders, policy-makers,
managers, and service providers learn how to shift their
approach to one of humility, seeking to understand with an
openness to learning and changing practices. Although this
journey has seemingly just begun, we celebrate the progress
that has been made and commit to continue the partnered
work that ultimately will close the health status gap for
Indigenous Peoples.
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