System-Level Change

Many policies and programs in their current form explicitly undermine Indigenous knowledge and practices. This occurs in many ways, related to such things as: content, structure, language, underlying values and assumptions, hiring practices, and more.

In order for system-level change to be meaningful and culturally safe, Indigenous knowledge and practices need to be centered at the outset. Only with this recognition will the remaining recommendations have a substantial impact.

As recommended by Goodkind et al. (2010), health systems should:

• Recognize and support traditional healers and other cultural leaders and knowledge-keepers as service providers
• Expand mechanisms for reimbursing them for their work and knowledge
• Provide funding for programs that serve a preventative function through cultural and community connectedness, and for programs that connect prevention with treatment
• Shift emphasis from evidence-based practice to practice-based evidence, which opens up room to value unique, culturally-grounded ways of being as legitimate health promotion

Cultural safety is an outcome of ongoing and organization-wide commitments to doing things differently. The Thunderbird Partnership Foundation (2020) provides a toolkit that outlines stepping stones to cultural safety. These include:

• Cultural humility: “Cultural humility has a number of important components, such as self-reflection, willingness to learn from the client, relationship building, and the concept of lifelong learning. … In addition, cultural humility ensures a less controlling, less authoritative style when communicating with clients” (p. 21).
• Critical reflection: This includes “more than becoming culturally aware or practising tolerance, it is the ability to identify and challenge one’s own cultural assumptions, values, and beliefs” (p. 22).
• Cultural awareness: “The outcome of this step would be the ability to identify both Western and Aboriginal knowledge and find ways to integrate them into practice. This step influences cultural sensitivity because it identifies what culture means from each perspective” (p. 22).
• Cultural sensitivity: “Health care workers should acknowledge cultural world views and modify conventional approaches and practices to suit the cultural world views of their clients. … [They] should be inclusive and culturally responsive to the differences among their clients rather than respond with assumptions” (p. 22).
• Cultural competence: This step includes understanding history, context, and power relations – including the impacts of historical trauma. It involves getting to know the culture of clients, and centering knowledge and practices that are important to them. It centers self-determination, supports cultural revitalization, and moves towards decolonization (p. 23).

• Reciprocity: “Reciprocity is about building the relationships between the client, health care practitioner, family, and community.” These relationships need to be meaningfully invested in (with time, human, and financial resources), and should occur at a community level (p. 23).
• Cultural safety: Cultural safety can only begin at this point. “Cultural safety is only determined by the client. It goes beyond the relationship between the health care provider and the client to ensure the health care environment is also culturally responsive” (p. 24).

As is made clear by the stepping stones above, cultural safety is a collective responsibility. Tait, Mussel, and Henry (2019) argue that change at the organizational level is a necessary condition for broader structural changes to be effective and sustainable, without doing further harm. These authors posit that micro-reconciliation supports the creation of “institutional pathways that seek to empower all levels of management and employees” (p. 26) and they set out three steps to micro-reconciliation:

• “Acknowledgement in local settings of the degree and impact of trauma and injustices experienced by Indigenous peoples” (p. 28)
• Witnessing, which calls for “human service sector workers to be a moral eye and voice … within the everyday local contexts” of their work (p. 30), and
• “The moral courage to name and speak what is known to be true” (p. 31) because this will inevitably launch “us into a moral discussion about what is important to collectively build systems that are not discriminatory to Indigenous peoples” (p. 32).

This kind of work “can only be done together, with Indigenous peoples driving the change” (p. 32). Micro-reconciliation is a necessary condition for the commitment to reconciliation that has been made at a national level, and is a necessary condition to address the health disparities that continue to exist in this country because of systemic inequities that persist.

There are endless possibilities! This website features many stories of communities and initiatives that offer great examples, and the Action Guide for Communities pulls together key learning from each of these stories.

Ensuring Indigenous youth are central to every conversation that impacts them – including at a system-level – is vital for meaningful change. See ‘We Matter’ below, for more.