Harfield et al.

Globalization and Health (2018) 14:12

DOI 10.1186/s12992-018-0332-2

REVIEW Open Access

Characteristics of Indigenous primary

health care service delivery models: a
systematic scoping review
Stephen G. Harfield1,2,4* , Carol Davy1,2, Alexa McArthur3, Zachary Munn3, Alex Brown1,4 and Ngiare Brown1,5

Abstract
Background: Indigenous populations have poorer health outcomes compared to their non-Indigenous counterparts.
The evolution of Indigenous primary health care services arose from mainstream health services being unable
to adequately meet the needs of Indigenous communities and Indigenous peoples often being excluded and
marginalised from mainstream health services. Part of the solution has been to establish Indigenous specific
primary health care services, for and managed by Indigenous peoples. There are a number of reasons why
Indigenous primary health care services are more likely than mainstream services to improve the health of
Indigenous communities. Their success is partly due to the fact that they often provide comprehensive programs that
incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants
of health. However, there are gaps in the evidence base including the characteristics that contribute to the success of
Indigenous primary health care services in providing comprehensive primary health care. This systematic scoping review
aims to identify the characteristics of Indigenous primary health care service delivery models.
Method: This systematic scoping review was led by an Aboriginal researcher, using the Joanna Briggs Institute Scoping
Review Methodology. All published peer-reviewed and grey literature indexed in PubMed, EBSCO CINAHL, Embase,
Informit, Mednar, and Trove databases from September 1978 to May 2015 were reviewed for inclusion. Studies were
included if they describe the characteristics of service delivery models implemented within an Indigenous primary health
care service. Sixty-two studies met the inclusion criteria. Data were extracted and then thematically analysed to identify
the characteristics of Indigenous PHC service delivery models.
Results: Culture was the most prominent characteristic underpinning all of the other seven characteristics which were
identified – accessible health services, community participation, continuous quality improvement, culturally appropriate
and skilled workforce, flexible approach to care, holistic health care, and self-determination and empowerment.
Conclusion: While the eight characteristics were clearly distinguishable within the review, the interdependence between
each characteristic was also evident. These findings were used to develop a new Indigenous PHC Service Delivery Model,
which clearly demonstrates some of the unique characteristics of Indigenous specific models.
Keywords: Primary health care, Models of care, Service delivery, Indigenous, Aboriginal and Torres Strait Islander,
American Indian and Alaska Native

* Correspondence: [email protected]
1
Wardliparingga Aboriginal Health Research Unit, South Australian Health
and Medical Research Institute, Adelaide, South Australia, Australia
2
School of Public Health, Faculty of Health Sciences, The University of
Adelaide, Adelaide, South Australia, Australia
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Harfield et al. Globalization and Health (2018) 14:12 Page 2 of 11

Background comprehensive PHC. This systematic scoping review

Indigenous populations have poorer health outcomes sought to address this gap by identifying the characteris-
compared to their non-Indigenous counterparts [1]. The tics (values, principles, and components) of Indigenous
experience of colonisation, and the long-term effects of PHC service delivery models.
being colonised, has caused inequalities in Indigenous
health status, including physical, social, emotional, and
mental health and wellbeing [2]. For example, in 2012 Method
the gap in life expectancy between Aboriginal and In 2015, the Leadership Group as part of The Centre of
Torres Strait Islander Australians and non-Indigenous Research Excellence in Aboriginal Chronic Disease Know-
Australians was 10 years [3]. Similar gaps in life expect- ledge Translation and Exchange, identified the need to
ancy exist in New Zealand [4], Canada [5] and the document the characteristics of Indigenous PHC service
United States [6]. delivery models. Guided by the Leadership Group, a re-
The evolution of Indigenous primary health care view team was formed comprising one Aboriginal [SH]
(PHC) services arose from the inability of mainstream and three non-Indigenous researchers [CD, AM, ZM]. A
health services to adequately meet the needs of Indigen- key feature of this review was the combination of perspec-
ous communities [3, 7, 8]. It was also a response to the tive and skills that the Leadership Group and the re-
reality that Indigenous peoples were often excluded and searchers brought to the project. This included expertise
marginalised from mainstream health services [9]. Part in systematic and scoping reviews as well as an under-
of the solution has been to establish Indigenous specific standing of Indigenous beliefs, values and experiences.
PHC services, for and managed by Indigenous peoples. A scoping review methodology was chosen, as it is the
In Australia, the first Aboriginal PHC service was most appropriate methodology for synthesising a body
established in 1971 [9] and there are now over 150 of evidence that has yet to be comprehensively reviewed
Aboriginal Community Controlled Health services [19]. Additionally, scoping review methodology is ac-
across the country [10]. In New Zealand, health re- knowledged as appropriate method to identify concepts
form in the early 1990’s led to the development of or characteristics in the literature [19], such as the char-
Māori health providers. This has resulted in a com- acteristics of Indigenous PHC service delivery models.
bination of national and locally controlled Māori led This systematic scoping review followed the Joanna
initiatives that are committed to improving Māori Briggs Institute Scoping Review Methodology [20]. The
health [7]. In Canada, the enactment of the Health review team developed and published a protocol prior to
Transfer Policy in the late 1980’s initiated the transfer commencing the systematic scoping review [21], that
of existing community-based and regional health ser- outlined the intended approach and method, which is
vices into First Nation and Inuit control [11, 12], and summarised below.
more recently the establishment of First Nations and
Inuit Health Authorities [13]. In the United States,
the provision of health services for American Indians Inclusion criteria
and Alaska Natives began as early as the nineteenth Concept – the characteristics (values, principles, and
Century and continued through the 1930’s, 1950’s and components) of service delivery models implemented
1970’s with a number of policy reforms, culminating within an Indigenous PHC service.
in what is now known as the Indian Health Services Context – PHC services that provided care predomin-
[14–16]. antly for Indigenous peoples.
There are a number of reasons why Indigenous PHC Indigenous peoples were defined as:
services are more likely than mainstream services to im-
prove the health of Indigenous communities. One of the Indigenous populations are communities that live
primary reasons is that Indigenous PHC services are within, or are attached to, geographically distinct
often controlled by their local communities [7, 13, 14, traditional habitats or ancestral territories, and who
17] and therefore are underpinned by the values and identify themselves as being part of a distinct cultural
principles of the communities they serve [18]. Their suc- group, descended from groups present in the area
cess is also due to the fact that they often provide com- before modern states were created and current borders
prehensive programs that incorporate treatment and defined. They generally maintain cultural and social
management, prevention and health promotion, as well identities, and social, economic, cultural and political
as addressing the social determinants of health [14]. institutions, separate from the mainstream or dominant
Despite their success, there are gaps in the evidence society or culture ([22](para. 1)).
base including the characteristics that contribute to the
success of Indigenous PHC services in providing Primary health care was defined as:
Harfield et al. Globalization and Health (2018) 14:12 Page 3 of 11

socially appropriate, universally accessible, scientifically inclusion criteria. During the two stages of study selec-
sound first level care provided by health services and tion, author one [SH] reviewed all studies and this was
systems with a suitably trained workforce comprised of checked by either one of the other three authors [CD,
multi-disciplinary teams supported by integrated refer- AM, ZM]. Any disagreements were discussed and re-
ral systems in a way that: gives priority to those most in solved by authors.
need and addresses health inequalities; maximises com-
munity and individual self-reliance, participation and
control; and involves collaboration and partnership with Charting of data
other sectors to promote public health. Comprehensive All papers were imported into QSR International’s
primary health care includes health promotion, illness NVivo 10 software [25] for extraction of reported char-
prevention, treatment and care of the sick, community acteristics. This analysis was initially conducted inde-
development, and advocacy and rehabilitation pendently by the four authors [SH, CD, AM, ZM]; [SH]
([23](para. 3)). checked the data extraction and analysis of the three
other authors [CD, AM, ZM], while a combination of
The above definitions ensured all reviewers shared the the other authors checked the data extraction and ana-
same understanding of Indigenous and PHC and all in- lysis initially conducted by [SH]. Any disagreements
cluded studies met the inclusion criteria. were discussed and resolved between the four authors.
Thematic analysis was used to group the extracted find-
Types of studies ings into characteristics. Findings were reviewed by
All study types and methods including grey (unpublished) members of the Leadership Group on two separate occa-
literature published in English between September 1978 sions during the synthesis process in order to provide an
and May 2015 were considered. Given that the concept of Aboriginal and Torres Strait Islander perspective on
PHC was broadly adopted in September 1978 [24], papers their validity.
prior to this date were excluded.
Results
Search terms The original search identified 2599 studies (Fig. 1), from
Aboriginal OR Aborigine OR Indigenous OR First which 402 duplicates were removed, leaving 2197 studies
Nation OR Maori OR Inuit OR American Indian OR for screening of title and abstract against the inclusion
Alaskan Native OR Native Hawaiian AND primary criteria. From this we retrieved 141 studies for full text
health care OR comprehensive primary health care OR review, of these 62 met the inclusion criteria (Add-
medical service OR health service OR community care itional file 2). Study selection follows the PRISMA
OR community health care AND model. reporting guidelines for study selection [26].

Search strategy
An initial search of PubMed was conducted to identify Description of studies
text words contained in the title and abstract as well as The majority of studies included in the review were
any index terms that could be used as alternate search conducted in Australia [27–58], 18 studies were con-
terms. A second, more detailed search was then under- ducted in the United States [59–76], five in Canada
taken using the identified search terms across PubMed, [77–81], four studies in New Zealand [82–85] and
EBSCO CINAHL, Embase, Informit, Mednar, and Trove. one study each in Papua New Guinea [86], Mexico
The detailed search strategy used for PubMed, which is [87] and Peru [88]. Of the studies included, the ma-
the basis for all other databases searched can be found jority of service delivery models focused on PHC ser-
in Additional file 1. The reference list of all identified vice delivery more generally [29–32, 34, 36, 40–42,
studies were also hand-searched for additional studies 49, 52–54, 56, 58, 61, 64, 66, 67, 69, 71, 73, 75, 76,
which met the inclusion criteria. As a final step, a post 81, 82, 84–86]; while the others studies focused on
was placed on ResearchGate to identify any additional specific areas such as women’s, maternal and infant
literature (particularly grey literature) which may not health [27, 45, 47, 57, 60, 78, 79, 87, 88]; mental
have been widely available through conventional health [70, 78, 80]; oral health [33, 39, 65]; eye health
databases. [62, 77]; adult health [38]; prevention and health pro-
motion [63, 72, 74]; public and environmental health
Study selection [59]; homecare [68]; prison health [50, 51, 55];
The selection of studies was performed by four of the asthma [35, 37]; diabetes [83]; alcohol and other
authors [SH, CD, AM, ZM] over two stages – title and drugs [46]; medicine access [89]; and continuous
abstract review; and full text review, against the quality improvement [28, 43].
Harfield et al. Globalization and Health (2018) 14:12 Page 4 of 11

Records identified through database Additional recordsidentified through

searching other sources
(n = 2,581) (n = 18)

Titles and abstracts of records screened after

duplicates removed
(n = 2,197)

Records excluded
(n = 2,056)

Full-text articles assessed

for eligibility
(n = 141)
Full-text articles excluded,
with reasons
(n = 79)
Studies included
(n = 62)

Fig. 1 Flow chart of study selection for scoping review process

Characteristics models and ensured the delivery of culturally appropri-

Of the included studies, eight characteristics of Indigenous ate care and made services more acceptable to Indigen-
PHC service delivery models were identified – accessible ous communities. Other practical examples of how
health services, community participation, continuous culturally appropriate service delivery was achieved,
quality improvement, culturally appropriate and skilled included creating welcoming [41] and comfortable
workforce, culture, flexible approach to care, holistic spaces [72], and family-friendly environments [48, 85],
health care, and self-determination and empowerment. through to for example, the use of Indigenous artwork
These characteristics underpin many of the service deliv- and Indigenous signage [27], and developing culturally
ery models in this review. appropriate prevention and health promotion resources
While culture was initially thought to be one of the [37, 50, 63, 72].
eight characteristics identified, it became evident Culture was strengthened in many instances by en-
through the process of thematic analysis, that it played a suring local languages were spoken within the service
central role and was embedded throughout all Indigen- [38, 41, 61, 72, 77, 80, 87, 88]. This was often
ous PHC service delivery models. Although the studies achieved through the employment of local Indigenous
did not provide a definition of culture in the context of staff who also acted as interpreters for non-
Indigenous PHC services, they did however demonstrate Indigenous health staff [81]. The employment of local
how aspects of culture were embedded within services Indigenous staff also incorporated aspects of cultural
and how culture is respected. mentoring [38, 45, 81] ensuring non-Indigenous staff
Pivotal strategies for embedding culture included the were culturally competent [45, 84] and aware of local
incorporation of local Indigenous cultural values [30, 54, protocols and values [58]. This contributed to ensur-
69, 73, 82]; customs and beliefs [38, 53, 75, 77, 79, 80, ing cultural safety, a concept which extended beyond
82, 85, 88], as well as traditional healing and practices being simply aware of cultural differences to incorp-
[36, 77, 79] into the service delivery model. Focusing on orating a deeper level of interaction and thoughtful
the needs of the individual and on the health and well- practice, as defined by those who receive services [38,
being of their families and communities [33, 34, 85]; re- 47, 48, 50, 52, 56, 66, 79].
specting women’s and men’s cultural needs [38, 41, 45, The other seven characteristics of Indigenous PHC
72, 87], such as women only discussing women’s health service delivery models are described in Table 1.
business with other women [45] or gender specific ser- While each of these characteristics were clearly identi-
vices and programs [41, 72, 87]; and ensuring the local fiable as independent themes within the literature, the
communities were engaged with [40, 85] and in control interdependence between characteristics was also evi-
of, Indigenous health services, [52, 79, 85] were ways in dent. As mentioned, culture was interwoven throughout
which culture was embedded into service delivery the seven other characteristics. Culture facilitated
Harfield et al. Globalization and Health (2018) 14:12 Page 5 of 11

Table 1 Characteristics of indigenous PHC service delivery Table 1 Characteristics of indigenous PHC service delivery
models models (Continued)
Accessible Health Services • recognising that Indigenous staff often have responsibilities and
• providing affordable health care [61, 87] at either no cost or low obligations in relation to family and community, which were often
cost [85]. conducted within the health service [54], such as interpreting and
• ensuring a broad range of services are available [50], in a variety of acting as mediators [78].
locations and settings [29, 30, 37, 41, 47, 49, 56, 71–73, 78, 80–82, 84, • providing training and development opportunities for all staff
87], including increased opening hours, walk in appointments [30, 32, 41, 47, 49, 50, 61, 64, 70, 74, 88], such as cultural awareness
[41, 47, 52, 60, 68, 76] and transport [47, 60, 72]. training for non-Indigenous staff [38, 58, 81], and comprehensive
• delivering acceptable care which focused on building trust with training for staff working in remote areas or in isolation who require
communities [87] ensuring patients felt supported [38] providing additional skills and knowledge to deal with an array of more com
assurances in relation to privacy and confidentiality [38, 80], and plex needs [61].
implementing services underpinned by cultural respect, social justice • training Indigenous Health Workers [30, 32, 49, 50, 61, 70] as a
and equality [47]. capacity building exercise [88], including more specialised health
• ensuring awareness in the sense that communities know the care such as dental [33, 39] or maternal health [47].
service exists by providing outreach and mobile services [82], • recognising the need to build and grow the Indigenous
participating in community events and holding screening days [38], workforce of the future by establishing long term strategies
encouraging patients to share their positive experiences and to mentor and recruit Indigenous students into health careers [80],
promote the service to others [71]. leading to Indigenous staff going on to further training or study [32].
Community Participation Flexible Approaches to Care
• ensuring Indigenous ownership of health services which enables • tailoring approaches to identify [36, 50, 55, 66, 72] and meet the
Indigenous peoples to own and manage their health service [85], needs of the local community [29, 38, 41, 47, 48, 50, 52, 54, 58, 64,
and ensures the service is accountable to the community [54]. 69, 70, 83, 87], and delivering a range of services [29], that are
• establishing Indigenous governance [30–32, 34, 35, 40, 60, 61, 64, relevant, culturally appropriate and effective [36, 82].
70, 82] including members from local community on governing • integrating health care services [38, 69, 76, 78, 80, 84], with a
boards, in order to encourage community involvement and multidisciplinary team approach [34, 49, 62, 67–69, 76], case
ownership, while at the same time building capacity within local management [33, 46, 67, 72, 76, 80], and continuity of care
communities [41, 50, 53]. [47, 48, 53, 56, 67, 68, 81, 84].
• facilitating community consultation, engagement and • partnering and linking with other services to promote
collaboration in order to establish a strong relationship with the integration and cooperation between all support services, providing
community [32, 84] and facilitate sharing of information [83, 88] holistic care through a social view of health [39, 41, 47, 51, 80].
ensuring that programs were culturally appropriate, accessible,
engaging and empowering, and designed to take account of the Holistic Health Care
local context and needs [34, 47, 54, 58, 74, 80, 82, 87]. • providing comprehensive primary health care, which is holistic
• respecting the role and status of elders [36] and facilitating their [32, 34, 37, 80, 82], supports the health and wellbeing of not only
involvement in the work and governance of services [45, 63, 66]. the individual but also their family and community [34, 49–51, 54,
66, 69, 73, 85], and includes mental, emotional and spiritual needs
Continuous Quality Improvement
alongside physical wellbeing [57, 60, 80, 84].
• collecting and utilising data not simply to improve health outcomes • offering a diverse range of services to clients [57], such as
but also meet the needs of each community by undertaking prevention and health promotion through to chronic disease care
program evaluation [29], participating in quality improvement
[29, 31, 34, 41, 53, 57, 62, 71], maternal and child health [34, 41, 49,
initiatives [28], reporting on performance [43], identifying clients
56, 57, 59, 82], oral health [39, 42, 50, 53, 57, 64, 65, 82], ear health
who require a specific service, follow-up visits and client tracking [53, 56, 64] sexual health [53], mental and social health [34, 41, 56,
[62], service planning and implementation [42, 64, 82], and service 57, 59, 78], alcohol and other drugs treatment [50, 53, 82],
impact [42].
pharmaceutical services [44, 56, 69, 78, 80], aged care [29, 36, 41]
• evaluating services to measure health benefits for the community
and disability services [41, 82].
[54], assessing economic outcomes, baseline demographics in
• including prevention and health promotion initiatives developed
relation to increased service utilisation, health assessments and
and tailored to the needs of the local community, including general
chronic disease care plans [42].
screening programs [29, 38, 63, 72, 77, 82] healthy lifestyles
• undertaking research to strengthen health systems in order to meet
programs [56] needle exchange programs [29, 33, 56, 82], women’s
the needs of the community with an emphasis on translating
and men’s health programs [29, 34], healthy eating, exercise and
research findings into practice [28].
smoking cessation programs [31, 32, 49, 52, 56, 71, 77], oral health
• establishing quality improvement processes with a focus on
[65], injury prevention [74], and supporting people to manage their
chronic conditions, monitoring health programs as well as
own health [71].
management and follow-up care [43, 62], and community
• improving health literacy particularly in relation to early warning
involvement in developing indicators [64], that also focus on
signs of suicide [70], increasing HIV/AIDs awareness [32], providing
cultural aspects of care, traditional approaches and receiving
information about the harm that comes from alcohol, tobacco and
care in language [80].
other drugs [73], understanding food labelling [83], maintaining
Culturally Appropriate and Skilled Workforce health and ensuring that people could detect early warning signs
• employing a range of skilled staff both health and non-health and understanding when to seek health care advice [71, 83].
personnel who are able to meet the needs of the local community • providing traditional healing as one option within the health
[30, 36, 41, 49, 50]. service [36, 52, 59, 63, 64, 70, 72, 73, 77, 79–82, 84–88].
• establishing an Indigenous workforce comprising Indigenous • advocating for clients [29, 52], especially in relation to clients
Health Workers, mental health workers, social workers, nurses, moving between other primary, secondary, tertiary, and essential
doctors, administration staff, managers and traditional healers, all non-health services [60, 84].
who are central to the delivery of services, providing a diverse range • engaging with the social determinants of health by
of care [37, 38, 41, 47, 50, 78, 81, 88], and within some service supporting clients in accessing housing, employment, education,
models, conducting the majority of the clinical work with clients social security payments, and supporting people through the
[31, 38]. justice system [29, 41, 49–51, 53, 56, 57, 59, 73, 80, 82],
Harfield et al. Globalization and Health (2018) 14:12 Page 6 of 11

Table 1 Characteristics of indigenous PHC service delivery and skilled workforce also enabled services to be access-
models (Continued) ible and acceptable, by building trust with communities
specifically for or customised to meet the needs of the [45, 83, 87], ensuring patients felt supported [38, 41],
community they served providing assurances in relation to privacy and confiden-
[32, 47, 84, 88].
• providing advice in relation to public health initiatives not within tiality [38, 80], and implementing services underpinned
the normal scope of mainstream PHC including sanitation system by cultural respect, social justice and equality [47].
construction and maintenance, disease surveillance, environmental As a result of identifying the characteristics of Indigen-
health, food distribution, and transportation [59].
• collaborating with other organisations such as schools, youth ous PHC service delivery models, we have identified and
groups, prisons, disability and aged care services [29, 32, 81], and described a new Indigenous PHC Service Delivery
with councils, liquor outlets and grocers to reduce the supply of Model, as depicted in Fig. 2. Fundamental to this model
harmful products while increasing the availability of healthy options
[29, 36, 47, 61]. is culture, as previously discussed culture plays a central
Self-determination and Empowerment
role in Indigenous PHC service delivery models; and is
• facilitating self-determination and empowerment of Indigenous encompassed by the seven other characteristics – access-
communities in order to establish and manage their own ible health services, community participation, continu-
Indigenous health services [30, 32], enabling clients to take control
of their own health, at an individual and family level [69], building
ous quality improvement, culturally appropriate and
resilience [53], and enabling empowerment of clients through skilled workforce, flexible approach to care, holistic
program engagement [34, 40, 47, 59, 74, 77, 83, 87]. health care, and self-determination and empowerment.
• providing employment and training to promote the development
of the local Indigenous health workforce, and build the capacity of
While Table 1 provides details as to how the characteris-
the community [32, 40, 41, 87]. tics have been embedded throughout other Indigenous
• facilitating leadership opportunities to ensure that Indigenous PHC service delivery models, they also act as examples
health care staff take on leadership roles within their communities
[32] and provide positive role models for other Indigenous peoples
of how the characteristics of the Indigenous PHC Ser-
[32, 70]. vice Delivery Model can be implemented within other
• promoting community development through the organisation of services.
activities beyond health care [36, 49], such as cultural days and
camps, reconciliation events and other community activities enable
communities to draw on culture, increase social connectedness, and Discussion
have pride in their identity [41]. The aim of this scoping review was to identify the charac-
teristics of Indigenous PHC service delivery models. We
assessable health services, informing the delivery of cul- found that culture underpinned all aspects of the Indigen-
turally appropriate services by making them acceptable ous PHC service delivery models identified in this review.
by the community [34, 47, 54, 58, 74, 80, 82, 87]. Culture In addition, we identified seven other distinct characteris-
was critical to ensuring community participation, enab- tics of Indigenous PHC service delivery models – access-
ling Indigenous ownership and governance by engaging ible health services, community participation, continuous
communities [30–32, 34, 35, 40, 60, 61, 64, 70, 82], and
engaging in quality improvement process and defining
outcomes and indicators [64]. Culture was important in
ensuring the approach to care is culturally appropriate
and relevant [36, 82, 83], and holistic including compre-
hensive and providing a diverse range of care, which in-
cluded traditional healing [36, 52, 59, 63, 64, 70, 72, 73,
77, 79–82, 84–88]. Culture informed and supported the
philosophy underpinning Indigenous self-determination,
particularly community participation, ensuring Indigen-
ous peoples having the right and determination to
decide how their PHC services should, and can be deliv-
ered [30, 33, 40, 49, 59, 69, 73, 82, 85].
Another example of interdependence between charac-
teristics is culturally appropriate and skilled workforce,
which was an enabler for culture, holistic health care
and accessible health services. Employing local Indigen-
ous staff helped to embed community cultural values,
customs and beliefs into service delivery [45, 77, 78, 81].
Workforce was central to the delivery of services, pro-
Fig. 2 Characteristics of Indigenous Primary Health Care Service
viding a holistic comprehensive PHC and a diverse range
Delivery Model
of care [38, 52, 83, 85, 87, 88]. A culturally appropriate
Harfield et al. Globalization and Health (2018) 14:12 Page 7 of 11

quality improvement, culturally appropriate and skilled Community participation was found to be particularly
workforce, flexible approach to care, holistic health care, important for ensuring Indigenous PHC services con-
and self-determination and empowerment. tinue to identify, understand and address the needs of
These findings suggest that Indigenous PHC service de- local Indigenous peoples. Community participation also
livery models are somewhat different to many of the facilitated Indigenous governance and ownership. One
models of care developed within western contexts. For ex- example is the Southcentral Foundation in Anchorage
ample, the Chronic Care Model [90] focuses on imple- Alaska, it is possibly one of the most well-known Indi-
menting evidence based care, mobilising community genous models of care (four of the included studies are
resources, enabling patient’s self-management, and ensur- from the Southcentral foundation [60, 64, 69, 76]). The
ing coordinated care and health promotion. The explicit success of this model, including significant improve-
role of culture in the provision of services is notably ab- ments in health outcomes is associated with the notion
sent from this model. Culture is also notably absent from of ‘customer-owners’ ([102] p. 1). The model ensures
the World Health Organisation Innovative Care for that Alaska Native people are in control of their health
Chronic Conditions Framework [91] and the Southgate service and the relationship that is built and maintained
Model of Comprehensive Primary Health Care in by the service with its ‘customer-owners’ ([102] p. 1).
Australia model [92]. Many of these services included in this review were also
By contrast, it is evident that local cultural values, cus- underpinned by the philosophy that Indigenous peoples
toms and beliefs were at the centre of and underpinned having the right to decide how their PHC services
all aspects of care in Indigenous PHC service delivery should be developed and delivered. Aboriginal Commu-
models. This was a common thread in the majority of nity Controlled Health Organisations in Australia have
the studies included in this scoping review. The role of been identified as exemplars of these types of commu-
culture as a defining characteristic, therefore, provides nity governance models [103], further demonstrating the
the greatest distinction between Indigenous PHC service link between community control and positive health
delivery and other models of care. This is consistent with outcomes.
the growing literature on culture and health, which Self-determination and empowerment were the driving
describes the importance of culture and its effect on principles behind the establishment of many Indigenous
health and wellbeing [2, 93–95], including in non- PHC services included in this review. Indigenous PHC
Indigenous populations [96]. These are potential lessons services facilitated a number of opportunities for self-
mainstream health care services could learn from in determination and empowerment. These include ensur-
order to make their services more culturally safe and ing that Indigenous peoples are able to take control of
appropriate to Indigenous peoples. Three characteristics their own health service; the employment and training
stand out as distinctive aspects of Indigenous PHC ser- of Indigenous peoples; and just as importantly commu-
vice delivery models. These are culturally appropriate nity development initiatives such as cultural days and
and skilled workforce; community participation; and camps, and reconciliation events. Previous studies have
self-determination and empowerment. At the heart of a demonstrated an association between empowerment of
culturally appropriate and skilled workforce were the Indigenous peoples and communities and better health
Indigenous staff. This supports the belief that Indigenous outcomes for Indigenous peoples [104, 105]. As on ex-
PHC services are best delivered by Indigenous peoples ample, a systematic review conducted by Minichiello et
[17]. In particular, employing local Indigenous staff helps al. [106], found that tobacco intervention programs
to embed the community’s cultural values, customs and which had elements of self-determination and were
beliefs into service delivery. Indigenous peoples provid- relevant to the community were more likely to lead
ing health care to their own people has been shown to to positive outcomes such as reduced initiation and
improve health outcomes related to diabetes [97], consumption of tobacco. Often self-determination and
asthma [98], mental health and maternal and infant care empowerment are associated with community partici-
[99]. Importantly, local Indigenous staff provide more pation. Community participation and mobilization in
acceptable care [100], as well as encouraging access to health care is essential for ensuring services can iden-
PHC more generally [101]. One of the many challenges tify health needs and set priorities, plan, implement,
faced by Indigenous PHC services is the need to main- monitor and evaluate services and programs, this is
tain current levels of Indigenous staff, while at the same consistent with existing literature on community par-
time, growing their Indigenous health workforce [66, ticipation in health [107].
80]. This requires a partnership between Indigenous Indigenous PHC service delivery models are excep-
PHC services and governments to ensure the growth of tional models of PHC, delivering health care to Indigen-
the sector is done in a way that is meaningful and cul- ous peoples and communities across the globe, often to
turally safe. isolated populations or communities where no other
Harfield et al. Globalization and Health (2018) 14:12 Page 8 of 11

service delivery model is viable. While there are numer- delivery models. These characteristics were found to be
ous benefits to Indigenous PHC service delivery models, global in their application, and provide insight and guid-
there are also limitations: Indigenous PHC service deliv- ance to communities and organisations wishing to initi-
ery models do not align with government funding mech- ate an Indigenous PHC service and programs. The
anism [108, 109]; there is often a lack of funding to review also affirms and supports the philosophy under-
support specific Indigenous PHC services [108–110]; the pinning Indigenous self-determination, particularly Indi-
need for services outweighs funding and the availability genous peoples having the right and determination to
of services [108–110]; and the delivery of health care to decide how their PHC services should be and can be de-
Indigenous peoples is more expensive [108, 109]. livered for themselves. If communities and governments
Policies need to acknowledge and take into account are genuinely serious about closing the gaps in life
the differences between Indigenous PHC models of care expectancy and morbidity between Indigenous and non-
and other PHC models of care. This is particularly cru- Indigenous peoples, then Indigenous PHC services must
cial when it comes to the funding of Indigenous PHC continue to be supported.
services, as the lack of sufficient funding together with
the uncertainty that comes from short-term funding Additional files
models led to the inability of services included in this re-
view to support the unique characteristics of Indigenous Additional file 1: Search strategy. (DOCX 13 kb)
PHC services [27, 32, 33, 40, 51, 54, 78, 82]. Funding Additional file 2: Included studies. (DOCX 16 kb)
models are one of the key drivers for how care is pro-
vided [111]. Yet it is also the case that until Indigenous Abbreviations
PHC: Primary Health Care
PHC service delivery models are clearly articulated, pol-
icy makers will not be able to design appropriate funding Acknowledgements
mechanisms to support the way in which they provide The authors would like to thank the Centre of Research Excellence in Aboriginal
care. We believe that the Indigenous PHC service deliv- Chronic Disease Knowledge Translation and Exchange Leadership Group for their
guidance and support; Assoc Prof James Ward (Infection and Immunity, South
ery characteristics identified by this scoping review is Australian Health and Medical Research Institute), Dr. Odette Gibson
one step towards making Indigenous PHC service deliv- (Wardliparingga Research Unit, South Australian Health and Medical Research
ery models explicit. Institute) and Prof Annette Braunack-Mayer (School of Public Health, The University
of Adelaide) for their comments on the final draft; and Eliza Cobb, (Marketing and
While this is the first review of its type to identify the Communications, South Australian Health and Medical Research Institute) for your
characteristics of Indigenous PHC service delivery graphic design skills.
models, a review by Lewis and Myhra on Integrated care
Funding
with Indigenous populations: a systematic review of the This research was supported by National Health and Medical Research
literature [112], was identified. However, that review Council (NHMRC No 1061242).
focused on assessing how health care services are con-
Availability of data and materials
ceptualising and enacting integrated care with American Not applicable.
Indian and First Nations populations in the United
States and Canada and the successes and challenges of Authors’ contributions
carrying out these interventions with this population. It NB, AB contributed to the conceptualisation of the review. SH, CD, AM and
ZM designed the search strategy, were involved with study selection and
identified the motivations for integration and its effect- review, analysis of data and drafting of manuscript. SH conducted the search.
iveness. Our review was more inclusive of health ser- All authors reviewed and approved the final manuscript.
vices and Indigenous populations from across the global
Ethics approval and consent to participate
and focused on the characteristics of Indigenous PHC Not applicable.
service delivery models rather than the motivations of
one particular service delivery model. Consent for publication
Not applicable.

Conclusion Competing interests

Indigenous PHC services evolved as a result of main- The authors declare that they have no competing interests.
stream health services inability to meet the needs of In-
digenous peoples [3, 7, 8] and Indigenous peoples often Publisher’s Note
being excluded and marginalised from mainstream Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
health services [9]. In addition, Indigenous communities
wanted to be able to provide care to their communities Author details
1
that is culturally appropriate, comprehensive, holistic, Wardliparingga Aboriginal Health Research Unit, South Australian Health
and Medical Research Institute, Adelaide, South Australia, Australia. 2School
accessible, and community controlled. The review iden- of Public Health, Faculty of Health Sciences, The University of Adelaide,
tified eight characteristics of Indigenous PHC service Adelaide, South Australia, Australia. 3Joanna Briggs Institute, Faculty of Health
Harfield et al. Globalization and Health (2018) 14:12 Page 9 of 11

Sciences, The University of Adelaide, Adelaide, South Australia, Australia. 26. Moher D, et al. Preferred reporting items for systematic reviews and meta-
4
Sansom Institute for Health Research, University of South Australia, Adelaide, analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.
South Australia, Australia. 5School of Education and School of Medicine, 27. The Dreamers - Art Therapy for Women. Aborig Islander Health Worker J.
University of Wollongong, Wollongong, NSW, Australia. 2002;26(6):10.
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Received: 8 October 2017 Accepted: 16 January 2018 strengthening primary healthcare. Implement Science. 2013;8:143.
29. Bartlett B, Boffa J. Aboriginal community controlled comprehensive primary
health care: the central Australian aboriginal congress. Australian Journal of
Primary Health. 2001;7(3):74–82.
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