Have investments in on-reserve health services and initiatives promoting community control improved First Nations’ health in Manitoba? Josée Gabrielle Lavoie a, * , Evelyn L. Forget b , Tara Prakash b , Matt Dahl c , Patricia Martens b , John D. O’Neil d a University of Northern British Columbia, Health Sciences Programs, 3333 University Way, Prince George, BC V2N 4Z9, Canada b Department of Community Health Sciences, University of Manitoba, Canada c Manitoba Centre for Health Policy, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba, Canada d Faculty of Health Sciences, Simon Fraser University, Canada article info Article history: Available online xxx Keywords: Canada First Nations Indigenous Primary health care Equity Policy Participation Generalized linear equations Ethnicity abstract The objective of this study was to document the relationship between First Nation’s community char- acteristics and the rates of hospitalization for Ambulatory Care Sensitive Conditions (ACSC) in the province of Manitoba, Canada. A population-based time trend analysis of selected ACSC was conducted using the de-identified administrative data housed at the Manitoba Centre for Health Policy, including vital statistics and health information. The study population included all Manitoba residents eligible under the universal Manitoba Health Services Insurance Plan and living on First Nation reserves between 1984/85 and 2004/05. Twenty-nine ACSC defined using 3, 4 and 5 digit ICD-9-CM and ICD-10-CM codes permitted cross-sectional and longitudinal comparison of hospitalization rates. The analysis used Generalized Estimated Equation (GEE) modeling. Two variables were significant in our model: level of access to primary health care on-reserve; and level of local autonomy. Communities with local access to a broader complement of primary health care services showed a lower rate of hospitalization for ACSC. We also examined whether there was a significant trend in the rates of hospitalization for ACSC over time following the signature of an agreement increasing local autonomy over resource allocation. We found the rates of hospitalization for ACSC decreased with each year following the signature of such an agreement. This article demonstrates that communities with better local access to primary health care consistently show lower rates of ACSC. Secondly, the longer community health services have been under community control, the lower its ACSC rate. Ó 2010 Elsevier Ltd. All rights reserved. Introduction Studies have repeatedly reported that the health of Indigenous peoples world-wide is poor, reflecting colonial and post-colonial policies that undermined Indigenous peoples’ cultures, languages and social structures, and resulted in widespread economic marginalization (Anderson et al., 2006; Stephens, Porter, Nettleton, & Willis, 2006). In recent decades, Indigenous peoples in many countries have sought to secure more control over community- based health services, in the hope of improving access and responsiveness (United Nations, 2002). This is seen by Indigenous peoples as an expression of their Treaty right (as in New Zealand) and/or Indigenous rights to self-determination (Laing & Pomare, 1994), rights that survived colonisation (especially in Canada and New Zealand, see Havemann, 1999 for a detailed discussion). Governments have responded by developing contractual relation- ships with Indigenous health organizations that provide a spec- trum of primary health care services, ranging from health promotion and prevention, to primary intervention and rehabili- tative services (Lavoie, Boulton, & Dwyer, in press). This shift echoes the Alma-Ata Declaration and the Ottawa Charter’s commitment to popular engagement in service planning and delivery (World Health Organisation & UNICEF, 1978, 1986; World Health Organisation Department of Communicable Disease Prevention and Health Promotion, 1997). In Australia, the number of Indigenous primary health care providers has grown to approximately 150 since they first emerged in 1971 (Dwyer, O’Donnell, Lavoie, Marlina, & Sullivan, 2009). In New Zealand, the sector grew from 23 providers in 1993e240 in 2007 (New Zealand Ministry of Health, 2007). In Canada, Health Canada reports that as of March 2008, 83 percent of eligible First Nation communities are involved in managing their own * Corresponding author. Tel.: þ1 250 960 5283; fax: þ1 250 960 5744. E-mail address: jlavoie0@unbc.ca (J.G. Lavoie). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.04.037 Social Science & Medicine xxx (2010) 1e8 Please cite this article inpress as: Lavoie et al., Have investments in on-reserve health services and initiatives promoting community..., Social Science & Medicine (2010), doi:10.1016/j.socscimed.2010.04.037