Navigating policy and infrastructure inequities in Indigenous primary health care: A qualitative comparative policy analysis of Alberta and Ontario

The capacity of primary health care (PHC) systems to provide high-quality, culturally safe care for Indigenous Peoples depends on strong and sustainable system infrastructure—including physical facilities, human resources, information systems, administrative supports, and equipment. This rapid qualitative policy study examined how PHC infrastructure is funded and resourced for Indigenous populations in Alberta and Ontario, comparing experiences from both provinces. Fourteen semi-structured interviews with key policy actors in both provinces were conducted, which informed the development of policy event timelines and enabled access to relevant provincial policy documents. The findings revealed that despite distinct provincial approaches, both juridictions face structural and juridictional barriers that hinder sustainable PHC delivery. Participants emphasized that salary-based payment models for physicians can support recruitment and rentention within First Nation and Métis communities, but alone are insufficient to address longstanding infrastructure gaps. Key barriers include geographic isolation, inadequate clinical space and technology, and limited clinical resources, which hinder PHC delivery, especially in remote and smaller communities. We identified funding inequities as a continuing barrier across both provinces, particularly concerning limited support for physician travel to rural and remote areas. The study also highlights how partnerships between First Nations and PHC organizations can mitigate infrastructure gaps when clinical resources are shared. Physician goodwill emerged as a key factor in improving access to PHC in remote regions, highlighting their commitment to go beyond contractual obligations and funding limitations to provide necessary services in Indigenous communities. The study highlights critical opportunities for policy reform, including expanded funding for system infrastructure, population-based funding, increased support for physician travel, and the recognition of Indigenous self-determination in health care planning. • Limited clinical resources and sparse Indigenous primary health care (PHC) system infrastructure hinder Indigenous Peoples’ access to quality, culturally safe PHC in Canada. • Many First Nation communities partner with physicians and PHC organizations via service agreements to improve on-reserve PHC access. Often, First Nations bear costs for auxiliary services, equipment, records, nursing, and more, without dedicated infrastructure funding from government. • Adequate recruitment and retention of physicians and health care personnel is a major barrier to care in rural and remote First Nation and Métis communities. Even if a community secures physician services, there may be no clinic space, equipment, or infrastructure for providers to live and work there. • Western definitions of the PHC system infrastructure overlook "cultural infrastructure," which includes integrating Indigenous perspectives into physical spaces and clinical services, cultural practices, and employing Indigenous health practitioners. • Physician goodwill, defined as a physician’s personal commitment and desire to serve Indigenous communities, plays a crucial role in motivating and retaining physicians in northern and remote communities.

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