HealthcarePapers 21(2) April 2023 : 28-34.doi:10.12927/hcpap.2023.27108

Action, Accountability and Transparency for Indigenous Health Systems Safety*

Richard T. Oster, Pamela Roach, Fiona Clement, Esther Tailfeathers, Bonnie Healy, Lori Meckelborg, Joanna Gladue and Patrick McLane


Anti-Indigenous racism is prevalent in Canada, especially within healthcare systems. Consequences are catastrophic, including deaths of Indigenous patients. Systems change and critical education guided by the Indigenous Peoples and research into how racism operates within healthcare settings are needed. In Alberta, promising initiatives are under way, including a First Nations-led initiative identifying racism and colonialism as key health determinants, novel experiential education, transformative education for senior health leaders and reframing health system measures to reflect Indigenous Peoples' perspectives. The time is now for comprehensive action toward eliminating racism within healthcare systems and fostering Indigenous health systems safety. Indigenous lives depend on it.


On July 12, 2022, an elderly patient waiting alone in visible discomfort for hours died in the emergency department (MacIsaac 2022) in New Brunswick. Shortly after, the province's health minister and the CEO of the health authority responsible for the hospital where the death occurred were removed from their posts, with hopes for immediate structural changes and action. Similar heartbreaking, unacceptable deaths of Indigenous patients in care have been widely reported in the Canadian media for decades. Why have politicians and health system leaders not consistently faced immediate, clearly linked consequences when racism leads to Indigenous patients' deaths? Why do providers infrequently face consequences? We believe that inequities in consequences signify underlying racism and inequities in healthcare that Indigenous Peoples continue to experience in Canada.

Anti-Indigenous racism is a major healthcare challenge as it remains systemically prevalent in Canada's healthcare system and in academic medicine and education of healthcare providers – as indicated in the many reports documenting experiences of Indigenous Peoples and communities (Government of Canada 1996; Leyland, Smylie, Cole, Kitty, Crowshoe, McKinney, Green, Funnell, Brascoupé, Dallaire and Safarov 2016; National Inquiry into Missing and Murdered Indigenous Women and Girls 2019; Truth and Reconciliation Commission of Canada 2015; Turpel-Lafond 2020; United Nations 2016). Related findings have been documented for decades, including a recent report on racism among Alberta physicians (Roach, Ruzycki, Hernandez, Carbert, Holroyd-Leduc, Ahmed and Barnabe 2022). Whether racism exists in our healthcare systems is not a question. What we need now are meaningful actions and solutions. Herein, we argue for systems change and critical education, grounded in new strengths-based research produced with, by and for the Indigenous Peoples. We outline promising initiatives under way in Alberta.

Need for Action on Health Systems Change and Critical Education Innovation

Systems change is crucial to effectively reduce anti-Indigenous racism. Legal ambiguity on which levels of government are responsible for Indigenous healthcare creates funding gaps and dizzying confusion for patients, providers and administrators (Richmond and Cook 2016). There is an immediate need to broadly apply policy akin to Jordan's Principle to healthcare (Assembly of First Nations 2018). Jordan's Principle specifies that when an Indigenous child requires financial supports, the first approached funder must pay and then seek reimbursement if they believe another funder is ultimately responsible. The same should apply across health needs to end gaps between federal and provincial systems. This may ultimately be less costly than the way systems are currently organized. Primary care gaps for Indigenous patients lead to a disproportionately high use of emergency care settings that serve them poorly (McLane, Barnabe, Holroyd, Colquhoun, Bill, Fitzpatrick, Rittenbach, Healy, Healy and Rosychuk 2021; Turpel-Lafond 2020), particularly for chronic conditions and holistic health (McLane, Mackey, Holroyd, Fitzpatrick, Healy, Rittenbach, Plume, Bill, Bird, Healy, Janvier, Louis and Barnabe 2022).

Critical education for health professional faculty, staff and students on issues that Indigenous Peoples face within healthcare systems is essential for advancing reconciliation, equity and justice within academic medicine and higher education (Jones, Crowshoe, Reid, Calam, Curtis, Green, Huria, Jacklin, Kamaka, Lacey, Milroy, Paul, Pitama, Walker, Webb and Ewen 2019; National Inquiry into Missing and Murdered Indigenous Women and Girls 2019; Truth and Reconciliation Commission of Canada 2015). Furthermore, everyone with the power to influence change within healthcare should follow Joyce's Principle (Council of the Atikamekw of Manawan and the Council de la Nation Atikamekw 2020), released by Joyce Echaquan's Atikamekw people following her death in a hospital. Joyce's Principle is the right of all Indigenous Peoples to equitable access – without discrimination – to all social and healthcare services, and the right to enjoy the best possible physical, mental, emotional and spiritual health. Moreover, health systems leaders need structural competency to increase cultural safety throughout institutions and to positively impact patient outcomes. It is critical for health systems leaders who can affect change in these domains to build these competencies in their own practice.

Action on health systems change and critical education must be guided by Indigenous-led research into how racism operates within particular settings (Jones 2002). For example, the Alberta First Nations Information Governance Centre has co-led research into how racism impacts the quality of emergency care, in partnership with the Blackfoot Confederacy, Stoney Nakoda Tsuut'ina Tribal Council, Maskwacîs Health Services, Yellowhead Tribal Council, the Treaty 8 Organization of First Nations of Alberta, Alberta Health Services (AHS) and university-based researchers. This research shows that First Nations patients are not prioritized for care during emergency triage compared with similar non-Indigenous patients (McLane, Barnabe, Mackey, Bill, Rittenbach, Holroyd, Bird, Healy, Janvier, Louis and Rosychuk 2022). It also demonstrates how racist stereotypes held by providers put First Nations patients at risk of poor emergency care (McLane, Mackey, Holroyd, Fitzpatrick, Healy, Rittenbach, Plume, Bill, Bird, Healy, Janvier, Louis and Barnabe 2022). Critical pedagogy that teaches emergency care providers how these stereotypes impact emergency care may help them actively counter deficits in care that First Nations patients experience. For healthcare providers to act from anti-racism education, they must see how it applies in their practice (Diffey and Mignone 2017).

A review of Indigenous cultural training programs suggests that cultural awareness frameworks (which educate about Indigenous culture and cultural differences) are largely insufficient in improving health services (Downing and Kowal 2011). A long-standing community-based participatory research (CBPR) partnership between community members from the Cree Nations of Maskwacîs, AHS and university-based researchers showed that some healthcare providers understand that passive education alone is not enough (Oster, Bruno, Montour, Roasting, Lightning, Rain, Graham, Mayan, Toth and Bell 2016). Furthermore, CBPR from Maskwacîs shows that ongoing experiential education – that includes shared learning, real-life experiences and positive relationship building with the Indigenous Peoples and their communities – helps initiate necessary reflexivity among healthcare providers to actively adopt care approaches that meet the specific needs of Indigenous patients (Oster, Bruno, Montour, Roasting, Lightning, Rain, Graham, Mayan, Toth and Bell 2016; Oster, Toth, Bell and ENRICH First Nations Community Advisory Committee 2021).

Promising Alberta-Based Anti-Racism Initiatives

In Alberta, promising Indigenous-led initiatives are under way for increased equity, health system transformation and anti-racism education. For instance, in May 2022, Treaty 6, 7 and 8 organizations convened a two-day meeting of all First Nations health directors in Alberta to plan efforts for countering racism in healthcare. Government and health system leaders were asked how they would address racism in healthcare. Indigenous organizations are simultaneously leading anti-racism work locally. G4 Health of the Stoney Nakoda Tsuut'ina Tribal Council identified racism and colonialism as key determinants of their people's health and made addressing these a priority (G4 Health of the Stoney Nakoda Tsuut'ina Tribal Council 2021). They are working to direct local hospitals and services in the next steps. Overall, there is a need to reassign resources from health and educational organizations to support Indigenous organizations and leaders, so that the Indigenous People do not bear the costs of addressing racism.

The Indigenous Wellness Core of AHS has begun offering experiential education for front-line care providers, including Indigenous-themed simulation education (AHS 2021). Training is designed for participants to apply learnings from cultural awareness/sensitivity courses to a simulated incident of racism in a clinical setting. Simulations are facilitated by a team of Indigenous and non-Indigenous actors and facilitators. Participants can reflect on knowledge, attitudes, beliefs and practices in a supportive environment. New Canadian Institutes of Health Research funding will support integrating findings from emergency care research (McLane, Mackey, Holroyd, Fitzpatrick, Healy, Rittenbach, Plume, Bill, Bird, Healy, Janvier, Louis and Barnabe 2022) into emergency department-specific simulation training, under the guidance of the Alberta First Nations Information Governance Centre, the Métis Nation of Alberta and other Indigenous partners.

A new program – Practical Leadership for University Scholars 4I: Reconciliation Leadership Foundations (PLUS 4I) – will support senior leaders in medical schools and AHS in developing structural competency and capacity to understand how to implement and support reconciliation initiatives in their areas (Moinul, Crooks, Lu, Roach, Keegan, Roze des Ordons and Kelly-Turner 2022). In turn, this could influence systems-level action leading to structural and organizational change. This work also created a critical reflective tool for educators, grounded in the needs of students, staff, faculty and Indigenous community members. With this tool, physicians and health professional educators can grow capacity in Indigenous health by promoting self-monitoring and peer auditing of anti-racism practices.

Relationship- and strengths-based CBPR with Maskwacîs – using Indigenous methodologies and practical, localized and invested research – has led to the implementation of an Indigenous-led intervention of experiential learning for perinatal healthcare providers and staff (Bruno, Bell, Parlee, Lightning, Bull, Cutknife and Oster 2022). Lunch-and-learn events were facilitated by Elders and community members, with participants attending powwow with an Elder guide, experiencing a sweat lodge ceremony and participating in a feast ceremony. Mixed-methods analyses found that participants felt better equipped to provide more culturally informed care after participating (Bruno, Bell, Parlee, Lightning, Bull, Cutknife and Oster 2022).

In addition to implementing innovative Indigenous-led initiatives, there is a distinct need to determine if efforts create change. A systematic review on educational interventions to reduce racism toward Indigenous Peoples in Canada's healthcare systems found that measured outcomes reflect what is considered effective by western standards and perspectives of healthcare providers (Farkas, Taplin, Akeju, Li, Lorenzetti, Dowsett and Clement 2021). Patient outcomes assessing whether interventions result in a perceived decrease in racism are not measured. None of the studies reported evidence of effectiveness from the perspective of the Indigenous People or communities. Evidence of practitioner behavioural change following training was scarce and had a high likelihood of bias.

In Alberta, research is under way to embed Indigenous patient experience measures in practice for continuous quality improvement in relational care via virtual Indigenous primary healthcare (Roach, Montesanti, Henderson, Barnabe, Crowshoe and Tailfeathers 2021). Ongoing CBPR with Maskwacîs includes collaborating on new impact measures that capture community-identified metrics, not just western outcome measures. For instance, community members designed the Maskwacîs Specific Cultural Scale to assess healthcare providers' cultural awareness and safety constructs specific to Maskwacîs, including questions on self-reflection and self-awareness in providing culturally safe care (Bruno, Bell, Parlee, Lightning, Bull, Cutknife and Oster 2022).


The time is now for extensive action toward eliminating racism within healthcare systems and fostering Indigenous health systems safety. Indigenous lives depend on it. Systems change and critical education are particular needs. Responsibility sits with all those who work within and for our healthcare and education systems. Accountability and transparency must be upheld at all levels to ensure multisectoral cooperation and progress. Working in collaboration through equitable, genuine partnerships with diverse Indigenous leaders, healthcare workers, patients, communities and Elders is vital to hearing and meeting the needs and care expectations of the Indigenous Peoples. We are taking some steps in the right direction, but we need a strategic, partnered, well-resourced and ongoing approach. The work of addressing racism in Canada's healthcare systems requires consistent, deliberate action across all levels of those systems. Also needed are mechanisms for Indigenous governance of health systems to ensure high-level provider accountability when racism results in harmful care and Indigenous patients' deaths.

About the Author(s)

Richard T. Oster, PhD, Scientific Director, Indigenous Wellness Core, Alberta Health Services, Adjunct Assistant Professor, Faculty of Agricultural, Life and Environmental Sciences, College of Natural and Applied Sciences, University of Alberta, Adjunct Assistant Professor, Faculty of Community Health Sciences, Cummings School of Medicine, University of Calgary, Edmonton, AB

Pamela Roach, PhD, Assistant Professor and Director of Indigenous Health Education, Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB

Fiona Clement, PhD, Professor and Department Head, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB

Esther Tailfeathers, MD, Senior Medical Director, Indigenous Wellness Core, Alberta Health Services, Kainai Nation, AB

Bonnie Healy, RN, Health Director, Blackfoot Confederacy Tribal Council Kainai Nation, Stand Off, AB

Lori Meckelborg, MPH, Director of Performance, Impact and Measurement, Indigenous Wellness Core, Alberta Health Services, Airdrie, AB

Joanna Gladue, MC, Health Promotion Facilitator, Indigenous Wellness Core, Alberta Health Services, Edmonton, AB

Patrick McLane, PhD, Assistant Scientific Director, Emergency Strategic Clinical Network, Alberta Health Services, Adjunct Associate Professor, Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, AB


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* For each in-text citation, the full list of last names of authors have been displayed rather than using “et al.” per style. All co-authors strongly agreed to this as a means to profile the work of Indigenous authors.


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