Building on Primary Care Reforms and Indigenous Self-Determination in the Northwest Territories: Physician Accountability and Performance in Context.

This commentary responds to Marchildon and Sherar's (2018) paper, "Doctors and Canadian Medicare: Improving Accountability and Performance," in which they explore questions around governance and physician accountability in Canada. This response situates the issues raised in a northern context by sharing experiences with primary care reform in the Northwest Territories and exploring the implications these changes have had for physician accountability and reported system improvements. Physician leadership and accountability are further explored in the northern context, where health systems for Indigenous communities include multiple jurisdictions and transitions in governance advance the self-government, land claims and treaty rights of Indigenous peoples.

Healthcare in Canada's North: Are We Getting Value for Money?

OBJECTIVE: To determine if Canadians are getting value for money in providing health services to our northern residents. METHOD: Secondary analyses of data from Statistics Canada, the Canadian Institute of Health Information and territorial government agencies on health status, health expenditures and health system performance indicators. RESULTS: Per capita health expenditures in Canada's northern territories are double that of Canada as a whole and are among the highest in the world. The North lags behind the rest of the country in preventable mortality, hospitalization for ambulatory care sensitive conditions and other performance indicators. DISCUSSION: The higher health expenditure in the North is to be expected from its unique geography and demography. If the North is not performing as well as Canada, it is not due to lack of money, and policy makers should be concerned about whether healthcare can be as good as it could be.

The prevalence of human papillomavirus and its impact on cervical dysplasia in Northern Canada.

INTRODUCTION: Certain types of the Human Papillomavirus (HPV) are sexually transmitted and highly associated with development of cervical dysplasia and cervical cancer but the distribution of HPV infection in the North, particularly amongst First Nations, Metis, and Inuit peoples, is little known. The purposes of the study are to identify the prevalence of type-specific HPV infections and the association of different HPV types with cervical dysplasia among women in Northern Canada. METHODS: This was a cross-sectional study with attendants of the routine or scheduled Pap testing program in the Northwest Territories (NWT), Nunavut, Labrador and Yukon, Canada. Approximately half of each sample was used for Pap test and the remaining was used for HPV genotyping using a Luminex-based method. Pap test results, HPV types, and demographic information were linked for analyses. RESULTS: Results from 14,598 specimens showed that HPV infection was approximately 50% higher among the Aboriginal than the non-Aboriginal population (27.6% vs. 18.5%). Although the most common HPV type detected was HPV 16 across region, the prevalence of other high risk HPV types was different. The age-specific HPV prevalence among Aboriginal showed a 'U' shape which contrasted to non-Aboriginal. The association of HPV infection with cervical dysplasia was similar in both Aboriginal and non-Aboriginal populations. CONCLUSIONS: The HPV prevalence was higher in Northern Canada than in other Areas in Canada. The prevalence showed a higher rate of other high risk HPV infections but no difference of HPV 16/18 infections among Aboriginal in comparison with non-Aboriginal women. This study provides baseline information on HPV prevalence that may assist in surveillance and evaluation systems to track and assess HPV vaccine programs.

Factors associated with human papillomavirus infection among women in the Northwest Territories.

BACKGROUND: In some regions, Aboriginal women have higher rates of cervical cancer compared to other Canadian women. However, little data are available regarding the co-factors of HPV infection in the Aboriginal population of Canada. We examined factors associated with high-risk human papillomavirus (HR-HPV) infection in a population of women (both Aboriginal and non-Aboriginal) in the Northwest Territories (NWT). METHODS: We used a cross-sectional design using a convenience sample of all women aged 14 years or older presenting for Papanicolaou (Pap) testing across all regions of the NWT from March 2009 to March 2010. Women answered a questionnaire on demographic characteristics, sexual behaviour, and gynaecological and obstetrical events. We used multiple regression analysis to explore factors associated with HR-HPV infection according to age and cultural background. HPV typing was done using the Luminex assay. RESULTS: Of the total 1,279 participants, 178 had missing HPV results. We obtained data on 1,101 women and overall HR-HPV prevalence was 14.2%. Younger age, single marital status, Aboriginal background, current smoking, lifetime deliveries, use of hormonal contraceptives, and the numbers of sexual partners in the last year were associated with prevalent HR-HPV. DISCUSSION: Our findings tend to indicate that Aboriginal women have different predictors of HR-HPV than non-Aboriginal women that may affect HPV progression to cervical cancer. These findings can help to better target public health practices for the women at higher risk of HPV infection and cervical cancer.