A Yukon First Nation Community’s Experiences with their Health System: A Territorial Perspective

The Yukon border sign greets travelers entering the territory from the Northwest Territories along the remote Dempster Highway. Photo: Carly J. Zulich

The Arctic Institute Health and Wellbeing Series 2025

• The Arctic Institute Health and Wellbeing Series 2025: Introduction
• Health and Wellbeing among Arctic Indigenous Peoples: Leveraging Legal Determinants of Health
• A Yukon First Nation Community’s Experiences with their Health System: A Territorial Perspective

Indigenous health has consistently been a complex issue within Canada, largely attributed to the ambiguities and discrepancies in health policies and legislations that result in jurisdictional debate over the responsibility of Indigenous health.¹⁾Kelly M (2011) Toward a New Era of Policy: Health Care Service Delivery to First Nations. The International Indigenous Policy Journal, 2(1); National Collaborating Centre for Indigenous Health (2011) ‪Looking for aboriginal health in legislation and policies, 1970 to 2008: the Policy Synthesis Project‬. Prince George, BC: National Collaborating Centre for Indigenous Health; Lavoie J (2013) Policy silences: why Canada needs a National First Nations, Inuit and Métis health policy. International Journal of Circumpolar Health, 72. This paper will outline the experiences of the First Nation of Na-Cho Nyäk Dun (FNNND), one of fourteen Yukon First Nations in the Yukon territory, with the health care system and health care delivery to their Citizens.

These complexities of Indigenous health can in part be traced back to policies and legislation that designated Indian Affairs as a federal responsibility, with the provision of healthcare to citizens as a provincial responsibility – all of which failed to delineate who is responsible for the health care of Indigenous peoples.²⁾Canada (1867) The Constitution Acts, 1867 to 1982.; Lavoie J, Forget E, & Browne A (2010) Caught at the crossroad: First Nations, health care, and the legacy of the Indian Act. Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 8(1).; Kelly M (2011) Toward a New Era of Policy: Health Care Service Delivery to First Nations. The International Indigenous Policy Journal, 2(1).; Lavoie J (2013) Policy silences.; Lavoie J (2018) Medicare and the care of First Nations, Métis and Inuit‬. Health Economics, Policy, and Law 13(3–4):280–298. The territories have an additional layer of complexity, as they were not originally included in the Canada Health Act (1984) which stipulated that the administration of hospitals, later interpreted to be all health services, was a provincial matter.³⁾Lavoie J, Forget E, & Browne A (2010) Caught at the crossroad.; Kelly M (2011) Toward a New Era of Policy. Lavoie J (2013) Policy silences.; Lavoie J (2018) Medicare and the care of First Nations, Métis and Inuit‬. Each territory subsequently underwent universal health transfers (the Northwest territories in 1988, the Yukon in 1997, and Nunavut in 1999) to create the three territorial health systems, each of which must meet the criteria outlined in the Canada Health Act to receive federal compensation.⁴⁾National Collaborating Centre for Indigenous Health (2011) ‪Looking for aboriginal health in legislation and policies, 1970 to 2008: the Policy Synthesis Project‬. Prince George, BC: National Collaborating Centre for Indigenous Health.; Government Of Canada and Indigenous Services Canada (2020) Working within the territorial health context: a framework to understanding and applying the northern lens. As a result, there are numerous unclear policies and legislations which fail to delineate who is responsible for Indigenous health, and the Indigenous health system has thus been described as a “patchwork” of policies and legislations.⁵⁾Lavoie J, Forget E, & Browne A (2010) Caught at the crossroad.; Kelly M (2011) Toward a New Era of Policy.; Lavoie J (2013) Policy silences.; Lavoie J (2018) Medicare and the care of First Nations, Métis and Inuit‬. This has subsequently resulted in fragmented health care delivery to Indigenous peoples, varying significantly by province and territory, resulting in a far from seamless health system. While the terms “Indigenous” and “First Nation” are terms that are of preferred use in Canada, the terms “Indian” and “Aboriginal” are sometimes referenced to be consistent with terminology that was used in historic policies and legislation.

There’s a substantial lack of information about the state of Indigenous health systems and the delivery of healthcare to Indigenous populations across the nation. Recent events, such as the death of Joyce Echaquan, have sparked national conversations about the deficiencies in healthcare for Indigenous communities. In response, the government has committed to address these gaps by engaging Indigenous organizations and communities to identify shortcomings of existing health systems and policies to guide future legislation. In light of the upcoming legislative reforms, it is imperative that the perspectives of underrepresented Indigenous communities are incorporated. Certain communities and nations may face inherent barriers that hinder the full inclusion of their perspectives in these reforms – this is likely the case for Yukon First Nations.

For example, the Assembly of First Nations (AFN) is a political organization representing approximately 634 First Nations communities across Canada, advocating on their behalf.⁶⁾Assembly of First Nations (2022) About AFN, Assembly of First Nations. https://www.afn.ca/about-afn/. Accessed on 16 January 2022. However, it is crucial to recognize that the AFN is solely an advocacy organization and does not represent the collective body of all First Nations in Canada. Moreover, since a significant number of First Nations communities are concentrated in British Columbia and Ontario, many of the issues the AFN advocates for may pertain specifically to those provinces.⁷⁾Government Of Canada (2017) First Nations population by provinces and territories, Canada, 2016. Statistics Canada, https://www150.statcan.gc.ca/n1/daily-quotidien/171025/cg-a002-eng.htm. Accessed on 1 April 2022); Yukon Government (2018) Find out about Yukon First Nations. https://yukon.ca/en/find-out-about-yukon-first-nations. Accessed on 16 January 2022. This situation can lead the government to mistakenly interpret the AFN’s voice as representing the entire First Nations community, making it challenging for other First Nations’ voices and perspectives to be heard. This disparity creates unique challenges for Yukon First Nations, such as the First Nation of Na-Cho Nyäk Dun (FNNND) in Mayo, as they endeavor to ensure their perspectives are adequately represented in legislative reforms.⁸⁾Yukon Government (2018) Find out about Yukon First Nations. https://yukon.ca/en/find-out-about-yukon-first-nations. Accessed on 16 January 2022).; H A (2021), personal communication.

The FNNND’s experience with the healthcare system is a shared experience of many First Nations in the Yukon, and in the North – insufficient health program and service provision, much of which is amplified by long standing jurisdictional debate between the federal and provincial/territorial governments over health service provision to Indigenous peoples, resulting in adverse impacts on overall community and individual health.⁹⁾H A (2021), personal communication. It is imperative that the perspectives of First Nations in the Yukon, particularly that of the FNNND, is meaningfully included in the co-development process.

Study Design

A qualitative case study design was used, gathering data through unstructured conversational interviews involving key informants who were either Citizens and employees of the FNNND, or closely affiliated with the FNNND, or and through document retrieval. The study received ethics approval from the University of Toronto Research Ethics Board, and the study was co-developed with personnel of the FNNND and was approved by the Chief and Council.

The study included four participants, totaling eight interviews. Two were active members and employees of the FNNND’s health and social service department, while the other two were long-standing personnel with extensive experience in negotiations and research within the FNNND. This diverse sample provided a comprehensive perspective on the FNNND’s health system constituents, such as government structures, policies, regulations, and financial arrangements. A thematic analysis was done following the coding of interview transcripts and collected documents, and the data was organized according to various health system building blocks (governing bodies, legislations, health service delivery) and the communities experiences of these building blocks.¹⁰⁾World Health Organization (2007) Everybody’s business: Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, Switzerland. https://www.who.int/publications/i/item/everybody-s-business—-strengthening-health-systems-to-improve-health-outcomes. Accessed on 9 February 2025. While the original study contained a comprehensive overview of all governing bodies, legislations, and service delivery to the FNNND, this paper offers a concise summary focusing on the most notable findings.

Results

Government of Canada

As embedded within the British North America Act (BNA), the Government of Canada bears responsibility for “Indian Affairs,” though this does not explicitly encompass Indigenous health, and the government has never formally claimed such responsibility. However, they do provide health services to select First Nations communities through Indigenous Services Canada (ISC). In the territories, ISC offers community-based health promotion, disease prevention programs, and the non-insured health benefits (NIHB) program to eligible Indigenous communities, but it does not deliver primary health services to remote, on-reserve First Nations as it does in the provinces.¹¹⁾National Collaborating Centre for Indigenous Health (2011) ‪Looking for aboriginal health in legislation and policies, 1970 to 2008: the Policy Synthesis Project‬. Prince George, BC: National Collaborating Centre for Indigenous Health.; Government Of Canada and Indigenous Services Canada (2020) Working within the territorial health context: a framework to understanding and applying the northern lens. Self-governing Yukon First Nations, such as the FNNND, have seen some community-based programs transferred to their control through Program and Service Transfer agreements, but the transferred programs and services face several limitations.¹²⁾The First Nation of NaCho Nyak Dun Self-Government Agreement (1993).; First Nation of Nacho Nyak Dun Self-Government Financial Transfer Agreement (2019).; Participant 3 (2022). For one, many of the programs are based off of those previously delivered to the Mayo Indian Band (the FNNND prior to the Self-Government Agreement) by Indian Affairs.¹³⁾Participant 3 (2022).; Participant 4 (2022). These programs, designed for southern contexts and are merely administered in the North, are outdated and fail to meet the community’s needs.¹⁴⁾The First Nation of NaCho Nyak Dun Self-Government Agreement (1993).; Participant 3 (2022).; Participant 4 (2022). Additionally, their funding models only consider Status First Nations, despite the FNNND’s Self-Government Agreement mandating the provision of programs and services to all of their Citizens, both status and non-status.¹⁵⁾The First Nation of NaCho Nyak Dun Self-Government Agreement (1993).; Participant 3 (2022).; Participant 4 (2022).

A notable example is the transfer of the National Native Alcohol and Drug Abuse Program (NNADAP) to the First Nation.¹⁶⁾Participant 4 (2022). NNADAP is a Health Canada initiative established in the 1970s, aimed to enhance local capacity in First Nations communities to address substance use.¹⁷⁾Government of Canada (2019b) National Native Alcohol and Drug Abuse Program. While this program supports residential treatment services in other provinces, there is reportedly no NNADAP-funded full-time treatment program available to First Nations in the Yukon.¹⁸⁾Participant 2 (2022). Instead, some NNADAP funding was transferred to the FNNND from ISC, intended to support a full-time NNADAP worker for the community. This has not been realized, as the funding for a NNADAP worker allocated by the Government of Canada is insufficient to even hire a part-time worker.¹⁹⁾First Nation of Nacho Nyak Dun Self-Government Financial Transfer Agreement (2019).; Participant 3 (2022).

ISC also administers the NIHB program to eligible First Nations and Inuit clients, which provides coverage for a range of peripheral health services.²⁰⁾Marchildon G, Lavoie, J & Harrold H (2021) Typology of Indigenous health system governance in Canada. Canadian Public Administration 64(4); Participant 2 (2022). Relevant to the FNNND is medical coverage for transportation to medical appointments – the community is located four hours away from Whitehorse, which is their primary hospital that provides emergent care, as well as secondary and tertiary health services such as specialist appointments.²¹⁾Participant 2 (2022). Oftentimes, FNNND Citizens must go to larger hospitals in Vancouver or Edmonton to get the services they require.²²⁾Participant 2 (2022). An overarching limitation of the NIHB program is its requirement for referrals through eligible health professionals at Government of Yukon medical centers, specifically the Mayo Health Centre for FNNND citizens.²³⁾Participant 2 (2022); Participant 2, Anonymous, 2022 Eligible health service providers, solely from the Government of Yukon, must make referrals and submit claims to NIHB offices.²⁴⁾Government of Canada (2019a) About the Non-Insured Health Benefits program, Government of Canada. For example, the First Nation community has explained that “as long as there’s a referral from the health centre, [the Government of Yukon] do the initial travel request arrangements and submit it to non-insured health benefits”.²⁵⁾Participant 2 (2022).

Departments of the FNNND lack referral authority for NIHB services, leaving access to these services contingent upon the Government of Yukon’s assessment of necessity.²⁶⁾Participant 1 (2022).; Participant 2 (2022). In certain cases, the First Nation may need to fund services upfront and await reimbursement.²⁷⁾Participant 2 (2022).

An additional NIHB service the FNNND community experiences challenges with is medical equipment. Typically, the FNNND must coordinate with the Government of Yukon’s homecare service or other health professionals at the Mayo Health Centre for assessments and equipment ordering, with claims sent to the NIHB office.²⁸⁾Participant 2 (2022). However, like emergency transportation, this process faces significant delays, often resulting in citizens not receiving timely medical equipment.²⁹⁾Participant 2 (2022). In urgent cases, the First Nation must collaborate with organizations such as the Red Cross in Whitehorse to borrow equipment until NIHB coverage is secured.³⁰⁾Participant 2 (2022).

Government of Yukon

 The Government of Yukon is currently under legislative obligation to provide insured health services to all of its residents, including Yukon First Nations and other Indigenous peoples living within the territory.³¹⁾Government Of Canada and Indigenous Services Canada (2020) Working within the territorial health context: a framework to understanding and applying the northern lens.; Participant 2 (2022).; Participant 4 (2022). Despite this obligation, “the services they provide specifically to First Nations though is very minimal”.³²⁾Participant 2 (2022). “As far as medical services go, it’s just the basic coverage that every other Yukoner gets”.³³⁾Participant 2 (2022). The FNNND accesses health services primarily through the Mayo Health Centre in the community, of which health services are delivered primarily through community nurses with occasional visiting physicians, or at one of the three hospitals in the Yukon.³⁴⁾Government Of Canada and Indigenous Services Canada (2020) Working within the territorial health context: a framework to understanding and applying the northern lens.; Participant 2 (2022). The Mayo Health Centre is a walk-in/outpatient primary care clinic which provides 24-hour emergency services and administers additional Government of Yukon programs and services.³⁵⁾Government of Yukon (2019) Mayo Health Centre, Yukon. https://yukon.ca/en/places/mayo-health-centre. Accessed on 26 July 2022. For approximately one week every month, although the frequency has decreased since the onset of the Covid-19 pandemic, there is a visiting physician who can be seen with the request of an appointment.³⁶⁾Government of Yukon (2019) Mayo Health Centre.; Participant 2 (2022). The community has many negative experiences with the health services received from the Government of Yukon – many often involved Citizens experiencing racism and being denied the standard of care treatment, leading to delayed diagnoses of illnesses and diseases that have improved outcomes when treated earlier on.³⁷⁾Participant 1 (2022).

The Government of Yukon also provides a variety of peripheral health services, such as substance use and addictions treatment. The FNNND can access Government of Yukon substance use and addictions services in both Mayo through the health center and in Whitehorse, and although this research was not able to get specific information to these individual programs, the community has reported negative encounters with both.³⁸⁾Participant 1 (2022).; Participant 2 (2022). Notable are the multiple barriers in place that prevent FNNND Citizens from accessing these services in a timely manner.

Many of the programs have unrealistic entry prerequisites. To enter a Government of Yukon substance use and addictions treatment program, the First Nation must refer their patient with the mental health worker at the Mayo Health Centre, who can then refer the patient to the services in Whitehorse.³⁹⁾Participant 1 (2022). In order to be referred to the services, the patient must undergo six counselling sessions with the mental health worker prior to referral, and the patient must undergo a detox period of at least five days.⁴⁰⁾Participant 1 (2022). This is challenging in itself for the First Nations, as there are no detox services or additional support within the town of Mayo besides the mental health workers at the Mayo Health Centre.⁴¹⁾H A (2021), personal communication. After meeting the entry requirements and being referred to the program, clients face long wait times.⁴²⁾Participant 1 (2022).

“And when they’re ready and willing to do treatment, sometimes a waiting list is two years long to some of these places…Like when they’re ready and willing, they’re ready and willing and if you don’t jump on it, you’re going to miss where they’re at. And so that doesn’t help.” – Participant 1

Additionally, the services provided by the Government of Yukon do not include aftercare to clients, and “once you come back home… you have to establish your own network of support”.⁴³⁾Participant 2 (2022). As a result, “it’s been a long time since (we’ve) sent anyone to a publicly-funded treatment program”.⁴⁴⁾Participant 2 (2022).

First Nation of Na Cho Nyäk Dun

The FNNND signed their Self-Government Agreement on May 29^th, 1993, which established their Government structure, allowing them to create subsequent governing bodies and enter transfer agreements that would increase local control over the programs and services delivered to FNNND citizens.⁴⁵⁾The First Nation of NaCho Nyak Dun Self-Government Agreement (1993).; First Nation of Nacho Nyak Dun Self-Government Financial Transfer Agreement (2019).; Participant 3 (2022). Within section 17 of the Self-Government Agreement, it is the authority of the First Nation to negotiate and transfer any program and service within their jurisdiction from both the Government of Canada and the Government of Yukon.⁴⁶⁾The First Nation of NaCho Nyak Dun Self-Government Agreement (1993).; First Nation of Nacho Nyak Dun Self-Government Financial Transfer Agreement (2019).; Participant 3 (2022). To date, only programs and services of the Government of Canada have been transferred, despite multiple attempts of the FNNND (and other self-governing First Nations in the Yukon) to negotiate for the transfer and assumption of programs and services from the Government of Yukon.⁴⁷⁾First Nation of Nacho Nyak Dun Self-Government Financial Transfer Agreement (2019).; Participant 3 (2022). Accordingly, the FNNND only has jurisdiction over administers programs and services related to community health, social services, assistance, and other services, and culturally-based programs to their citizens, with no jurisdiction over primary, secondary, and tertiary health services (which the Government of Yukon is responsible for).⁴⁸⁾Participant 1 (2022).; Participant 2 (2022).; Participant 3 (2022).

Despite these limitations in jurisdiction over health service delivery to their Citizens the First Nation have nonetheless taken initiative and responsibility for a variety of other health and social services to help improve the health and wellness of their community, including home care programs (assistance with basic home needs), social assistance, emergency care services and funding, transportation services, family support programs, and importantly, substance use and addictions services.⁴⁹⁾Participant 1 (2022).; Participant 2 (2022).; Participant 3 (2022).; Participant 4 (2022). Importantly, the FNNND designs and operates a variety of land-based programs and services to their citizens, which the community perceives to have a more positive impact on supporting wellness in comparison to Government of Yukon services.⁵⁰⁾Participant 1 (2022).

Discussions

This study aimed to gain a deeper understanding of the health system within the FNNND and its ability to meet the health needs of the community and highlighted many weaknesses in the services provided by various levels of government, and areas that could be improved. The community-based programs funded by ISC have proven to be of little relevance to the community, as they are programs designed with a southern, “Indian Act” perspective. Re-evaluation of the programs with a territorial perspective is necessary to ensure that communities are receiving programs (or funds for programs) that meet their unique needs, and to ensure that funding models support the delivery of these programs to the entire community. Furthermore, a thorough examination of the NIHB program’s implementation in the Yukon is necessary to better understand the processes of clients receiving services. Potential improvements would include granting Yukon First Nations the ability to make referrals for certain services as they have the best understanding of the needs of their community and Citizens.

While the Government of Yukon maintains the jurisdiction and responsibility for health care delivery and social service delivery to all of their residents, both Indigenous and non-Indigenous, it is evident that the services they are providing are not Indigenous-centric and are failing to meet many of the health needs of FNNND Citizens. The Government of Yukon must increase its collaboration with Yukon First Nations to enhance health policy and health systems, ensuring it reflects Indigenous perspectives. This may involve adapting healthcare delivery models to better align with the cultural needs of Indigenous populations in the territory.

The FNNND has compensated for deficiencies in Government of Yukon programs and services through its community and land-based initiatives. The results of this study support the existing body of knowledge and evidence that supports the inclusion of traditional healing practices, such as land-based camps, within government funding of the health system for Indigenous communities.⁵¹⁾Oster R et al. (2014) Cultural continuity, traditional Indigenous language, and diabetes in Alberta First Nations: a mixed methods study. International Journal for Equity in Health 13(1); Firestone M et al. (2019) “I feel safe just coming here because there are other Native brothers and sisters”: findings from a community-based evaluation of the Niiwin Wendaanimak Four Winds Wellness Program. Canadian Journal of Public Health 110(4): 404–413; Redvers J. (2020) “The land is a healer”: Perspectives on land-based healing from Indigenous practitioners in northern Canada. International Journal of Indigenous Health 15(1):90–107; Graham S et al. (2023) First Nations, Inuit and Métis Peoples Living in Urban Areas of Canada and Their Access to Healthcare: A Systematic Review. International Journal of Environmental Research and Public Health 20(11). Research highlights how turning to traditional processes can effectively support mental health and address challenges in Indigenous communities by integrating culturally grounded practices into health systems.⁵²⁾Carvill A (2020) Turning to Traditional Processes for Supporting Mental Health. The Arctic Institute – Center for Circumpolar Security Studies. https://www.thearcticinstitute.org/turning-traditional-processes-supporting-mental-health/. Accessed on 9 February 2025 Similarly, evidence suggests that adapting addictions programming in the Canadian Arctic to incorporate traditional approaches can foster better engagement and outcomes for Indigenous populations.⁵³⁾Tanche K (2020) Ways Forward in Addictions Programming in the Canadian Arctic. The Arctic Institute – Center for Circumpolar Security Studies. https://www.thearcticinstitute.org/ways-forward-addictions-programming-canadian-arctic/. Accessed on 9 February 2025 Incorporating traditional healing practices, including land-based camps, into the government funding of the health system aligns with a more culturally safe and responsive approach to First Nation health.

Limitations

The original research provided a preliminary exploratory analysis of the health system of the FNNND, and examined health system building blocks such as the governance structures and service delivery and the community’s experience with these elements. Due to the time constraints of the study, a comprehensive analysis that examines other health system building blocks, such as workforce and financing, and health outcome data was not able to be performed. Furthermore, this study included a relatively small sample size of participants that was made up of informants exclusively affiliated with the FNNND. Although Government of Yukon staff refused to participate in the study, future research should seek to include these additional perspectives for a more balanced overview of the health system of the FNNND and other Yukon First Nations.

Conclusion

The present study aimed to investigate the efficacy of the health system of the FNNND concerning its ability to address the health needs of its community members, and illuminated various challenges encountered by the FNNND community in accessing sufficient health services. This study is one of the few to concentrate on First Nations health systems situated above the 60th parallel. While findings resonate with previous research on health transfers to First Nations in provinces, this study offers unique insights into the perspectives of First Nation communities navigating territorial health systems and overlapping self-government agreements. The findings underscore the need for ongoing research and evidence-based policy development in the territories to improve health systems for Indigenous communities effectively.

Carly J. Zulich is a medical student at the University of Manitoba, who did a Master of Art in Northern Studies through Carleton University and a subsequent Master of Science in Health Policy, Management, and Evaluation through the University of Toronto. Throughout her masters work, she worked with the First Nation of Na Cho Nyäk Dun.