Moving towards cultural safety in mental health and addictions contracting for urban Indigenous Peoples: Lessons from British Columbia

In response to the inequities in health and health care that Indigenous communities continue to experience, governments in many countries have used contracting as a policy mechanism to improve access to culturally safe health services. Case studies from New Zealand, Australia and Canada demonstrate the equity-promoting potential of contracting-out interventions within the Indigenous primary health care (PHC) sector. At the same time, these studies have heightened concerns about the exigencies of contract reform within increasingly neo-liberal climates. To foster accountability for health equity, more needs to be known about how current contractual arrangements, intended to support Indigenous community-based systems of care, actually fit with the evolving needs, priorities and contexts of Indigenous communities in Canada. In this project, I use a qualitative design and ethnographic methods to examine urban Indigenous Providers’ experiences with contracting for culturally safe mental health and addictions care within one Canadian province, British Columbia (BC). Critical theoretical perspectives and input from Indigenous advisors informed my inquiry. In addition to a critical policy review, I conducted in-depth interviews with Indigenous and non-Indigenous people within seven Indigenous and one non-Indigenous provider organizations (n=23), including senior administrators, managers and mental health care providers. I also interviewed policy and funding decision-makers and contract managers in the area of Indigenous mental health (n=10). Examining contracting for culturally safe mental health and addictions care from the perspective of urban Indigenous Providers in BC sheds light on the ways in which current funding structures, policies and contractual approaches mediate wider ideological constraints and impinge, often inadvertently, upon organizations’ capacities to develop and effectively deliver mental health care services that safely meet the intersecting needs of their communities. Neo-liberalism, the ongoing dominance of biomedicine within the broader health care system, the legacy of colonialism, race, gender and class intersect to simultaneously reproduce, reinforce and obscure colonial and neo-colonial patterns within contractual relationships, mental health programming and care. These findings have important policy implications for funders and support the call for an alternative framework to contracting that articulates equity as an explicit dimension of accountability and Indigenous culturally safe mental health and addictions care.