This study demonstrates the ability of a modified Delphi approach to achieve consensus among a geographically dispersed and professionally diverse group of stakeholders. Through this structured consensus process, we selected a core group of performance indicators and identified other important indicators for further consideration and development. The eleven core indicators (Table 2), are largely focused on morbidity and mortality. This is consistent with the findings of our earlier work (15) and reflects the historical dominance of physical health outcomes in performance measurement and health surveillance systems. Physical health outcomes provide the most straightforward opportunity for standardizing definitions and collecting high quality data. The validity and reliability of these indicators is also well established in the literature. A more interesting and impactful outcome of the study is the identification of 29 additional indicators for further consideration (Table 3). These indicators, which were identified using importance and relevance as gateway criteria, demonstrate interest in evaluating Northern health system performance through the domains of social determinants of health, healthcare accessibility, and health system responsiveness. Themes related to travel for care and the availability of culturally appropriate care weave throughout each domain.
Social and structural determinants of health such as income, education, social support, gender, and experiences of racism are all known to influence health behaviours, health system access and health outcomes (31–34). Important social determinants of health highlighted in this study include maternal education, the presence or absence of intimate partner violence, food insecurity and inadequate housing. While there is strong evidence that Northern communities are disproportionately affected by these challenges, they are not routinely included in perinatal health surveillance.
In Alaska, the Northern Canadian Territories and Greenland, the structural, political, and social determinants of health are compounded by physical isolation, increased industrialization, changing environmental conditions, and long winters. These factors contribute to the geographical and logistical barriers that Northerners face when accessing healthcare. Multiple indicators of healthcare access were highlighted in this study. These include but are not limited to the number of antepartum or postpartum visits a patient is able to attend, the availability of obstetrical ultrasound, and the distance a patient is required to travel for care. The latter indicator was identified from the Canadian Maternity Experiences Survey (35) and captures the proportion of women who report traveling > 100 km to receive care. It is important to remember that in many Northern regions around the world, distances are almost always greater than 100 km. With this in mind, the Delphi panel suggested other measures of travel for care including the proportion of women who can access a maternity care provider (and/or skilled birth attendant) in their community, the number of unplanned births occurring in each community (which generally occur as a result of patients being unable or unwilling to travel for birth), and the number of emergency transfers for obstetrical indications. If “distance” to care is measured within a Northern context, we suggest using the number of “days or hours away from home” as a more appropriate reflection of the travel burden. The Delphi panel also suggested that an indicator be developed to capture the proportion of women in a region receiving care in their own language. This, of course, reflects the fact that accessibility is not equivalent to geographical proximity and equitable access to care requires that systems and providers minimize social, financial and systematic barriers to care and ensure the availability of culturally safe care for Indigenous women.
Health system responsiveness is a concept intended to capture the ability of a health system to acknowledge, accommodate, and react to the expectations of the population. It shares many tenants with patient centered care and cultural competency (36). For Indigenous women, providing culturally competent and thus responsive care may necessitate a holistic appreciation of health (37, 38) including physical, mental, emotional, spiritual, and historical considerations. It is well established that racism, colonization, and self-determination are important determinants of Indigenous peoples’ health and are major drivers of health inequities (10, 39, 40). The Delphi panel demonstrated this critical issue by selecting multiple indicators reflective of cultural competency or safety or other aspects of the patient experience. These indicators include a number of patient reported outcomes in order to reflects the importance of assessing cultural safety through the eyes of the individual, family or community receiving care. Our study suggests that Northern health care providers, institutions and systems should not only prioritize efforts to provide culturally safe care, but should also measure and report on their ability to do so.
While many of the selected indicators are not ready for implementation as they have been presented here, Northern health regions interested in improving their use of contextually relevant performance indicators, may find this a useful resource. This study was initially intended to take on a circumpolar approach. However, due to the geographical distribution of participating experts, it can more accurately be applied to Alaska, the Northern parts of Canada, and Greenland. Of course, other Northern or rural/remote regions may find that our findings can be adapted for their context. As presented, many of indicators outlined in this study do not currently demonstrate the scientific rigor to allow for immediate use. This is due to a variety of factors including the complex nature of the constructs being measured, the availability of data sources to support these indicators, and the willingness of health systems leadership to direct resources toward development of indicators for small populations. In order to prepare these indicators for use at local, regional or national levels, we recommend that further indicator development be carried out in consultation with patients, families, community leaders as well as other local stakeholders. Concomitant development and application of region-specific health performance frameworks will help to maintain comprehensiveness and relevance while minimizing indicator redundancy.
Beyond the specific indicators identified by the Delphi panel, our findings highlight some important challenges and opportunities for Northern performance measurement initiatives. First, when reporting rare outcomes among small populations, aggregation of data over large regions or timeframes may be required to ensure confidentiality and statistical rigor. Thus, there may be a larger role for process indicators and for confidential audits of rare outcomes such as maternal and neonatal mortality. Second, health system performance measurement is only as effective as the data that supports it. In the Canadian territories, for example, there is limited prospective collection of perinatal surveillance data. There is also a marked lack of Indigenous specific identifiers within Canadian health data sources more broadly (41, 42). The development and implementation of Indigenous health information systems in Canada is essential and must be carried out with and by Indigenous communities and organizations to ensure appropriate indicator selection, data usage and governance (43, 44). Finally, and most importantly, our findings reinforce the fundamental role of context and values within health system stewardship (6, 17, 45) and the importance of aligning health policy with broader agendas (46). In Canada, we have seen the recent adoption of the UN Declaration on the Rights of Indigenous Peoples and the release of the final reports of the Truth and Reconciliation Commission and the Inquiry into Missing and Murdered Indigenous Women and Girls (47–50). In association with these reports, Canadian National bodies have begun to recognize the importance of Indigenous rights and self-governance. Despite this, the commonly used performance measurement systems are still incongruent with these values. Canadian policy makers thus have an opportunity and an obligation to engage with northern stakeholders and Indigenous communities to ensure that health policies and resources are directed appropriately. Furthermore, when developing performance measurement strategies intended to capture and address health inequities, it is critical to recognize the role that defect-based approaches to health surveillance have had and continue to have on the stigmatization of Indigenous peoples within the health literature. Adequate engagement and attention to strengths-based approaches can limit this unintended consequence while simultaneously providing opportunities for health system improvement and management.