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Structures last longer than intentions: creation of Ongomiizwin – Indigenous Institute of Health and Healing at the University of Manitoba

ABSTRACT Ongomiizwin – Indigenous Institute of Health and Healing at the University of Manitoba’s Rady Faculty of Health Sciences (RFHS) was launched in June of 2017 with a mandate to provide leadership and advance excellence in research, education and health services to achieve health and wellness for Indigenous peoples and to implement the Truth and Reconciliation Commission of Canada’s Calls to Action within the Faculty. The RFHS Reconciliation Action Plan has five broad themes: (1) Honoring traditional knowledge systems and practices, (2) Safe learning environments and professionalism, (3) Student support, mentorship and retention (4) Education across the spectrum and 5) Closing the gap in admissions. Community engagement is the focus of our work. Learners and practicing clinicians are grounded in the knowledge of ongoing colonial harms, engaged in critical self-reflection on one’s own biases and trained to confront anti-indigenous racism in health care. This alignment is changing the health human resource landscape in northern Manitoba and beyond.


Introduction
Indigenous (First Nations, Métis and Inuit) communities in Canada experience substantial barriers to accessing health services, and consistently have unmet health care needs. Relatedly, many communities have limited involvement in the governance, design, and delivery of health care [1][2][3]. The Truth and Reconciliation Commission (TRC) of Canada situated the health disparities experienced by Indigenous peoples as the persistent consequences of the Indian Residential Schools system. Following the completion of the commission's hearings, the TRC released a final report and a summary of 94 Calls to Action in June of 2015, which included specific calls for transformation in the health care system.
Many jurisdictions across Canada have attempted to redress health inequities for Indigenous people through partnerships with universities that engage in health education, research, and service delivery [4]. However, most of these partnerships and the projects they produce have left colonial power structures intact [5][6][7]. At the University of Manitoba, decades of foundational work by Indigenous leaders and their allies led to the creation of Ongomiizwin -Indigenous Institute of Health and Healing, launched on 2 June 2017. Ongomiizwin is the Anishnabemowin name given to the Institute through ceremony by a council of Elders. The concept is understood to mean "clearing a path for generations to come." Ongomiizwin has committed to doing this in partnership with First Nations, Metis and Inuit Communities, guided by Elders and Traditional Knowledge Keepers.
The mandate of the Institute is to provide leadership and advance excellence in research, education and health services to achieve health and wellness for Indigenous peoples, and to implement the TRC of Canada's Calls to Action within the Faculty through the development and implementation of a TRC Action Plan. In this overview, we will explore the origins of the Institute, the work it is engaged in, and some of the early successes.  [9]. For almost 50 years, the central mission of the University of Manitoba's Northern Medical Unit has been the delivery of health care, the pursuit of medical and paramedical research, and education of health practitioners for the communities in the remote North.

Early developments in Indigenous-led health services and research
Beginning in the late 1990s, the University of Manitoba created additional opportunities to include Indigenous representation and governance in the academy. This

Centring Indigenous cultures in academic culture
Successful change occurs when opportunity is met with influence and readiness [10]. The clustering of the health professional colleges and the release of the TRC Calls to Action aligned with a critical mass of Indigenous leadership and influential non-Indigenous academic leadership, which together served as a catalyst for redesigning the academic organisational culture with Indigenous culture. Through consultation with faculty and staff and in direct response to the TRC, the RFHS identified broad themes for institutional change that were necessary to transform the academic culture into one centred around Indigenous culture and rights. The themes included: (1) Honouring traditional knowledge systems and practices (Call to Action 22), (2) Safe learning environments and professionalism (Call to Action 23 and 24), (3) Student support, mentorship and retention (Call to Action 23), (4) Education across the spectrum (Call to Action 23) and (5) Closing the gap in admissions (Call to Action 23) [11].
The RFHS developed an Action Plan with a working group for each theme chaired by Indigenous and non-Indigenous faculty or staff of the RFHS. As a collective, the working groups identified six imperatives to guide the integration of Indigenous culture and ways of being in the proposed structure. The imperatives included relationship building, recognition of rights, reconciliation and respect, reflective programs and practice, recruitment and retention, and anti-racism. Centring these concepts was considered critical to move from mere talk about reconciliation to action. These guiding principles were operationalized in a variety of ways throughout the process of addressing the TRCs Calls to Action. In the next section, we provide some examples of "how" the working groups centred the imperatives in bringing about institutional change in medical education, service delivery and research.

Transforming medical education and practice
Since the official launch of Ongomiizwin and the unveiling of the Action Plan, steady progress continues to be made towards the measurable landmarks. To Honour Traditional Knowledge Systems and Practices, a new inter-professional experiential learning opportunity was launched in the summer of 2017. In 2018, 21 students from 8 different professional programs within the 5 health sciences colleges visited one of five First Nations communities in Manitoba. Each community hosted a group of students for 2 weeks with the goal of providing the students with an opportunity to learn about a community, its people and culture, and the organisation of health services within a rural or remote area. The secondary aim was to support student skill development in interprofessional collaboration.
Towards the goal #2, Supporting Safe Learning Environments and Professionalism, the RFHS has provided access to the Manitoba Indigenous Cultural Safety online training course for faculty members. This asynchronous, modular course completed in 8-10 h over 8 weeks, links the history of colonisation in Canada, and its impact on the health and wellbeing of Indigenous peoples. The course challenges participants to consider how health professionals can make changes to stop the harms of anti-Indigenous racism in health care environments [12].
For goal #3, Moving to Close the Gap in Admissions, Ongomiizwin continues to partner with the Manitoba Healthcare Providers Network, and the university's outreach program which seeks to connect with and support Indigenous youth in rural, remote and inner city communities during and after the admissions process for health professional programs including medicine, nursing, and graduate programs in health research [13-15]. In addition, Ongomiizwin faculty are actively involved in the admissions process where they identify potential policy gaps or barriers impacting prospective Indigenous students.
Starting in 2010, as part of the curriculum renewal for undergraduate medical, two Indigenous scholars and clinicians from Ongomiizwin developed a longitudinal course in Indigenous Health (60 h over 4 years) in consultation with an Indigenous community advisory group. The curriculum of the course aims to help students recognize the ongoing impact of colonial systems on the health and wellbeing of Indigenous people [16,17].
In 2009, a dedicated family medicine residency stream focused on northern and remote practice was developed. The program has capacity to train 15 residents per year in the knowledge, skills and attitudes necessary to provide high quality care in remote Indigenous communities. Residents accepted into the program sign a 2-year returnof-service agreement with the provincial department of health to practice in a remote or Northern Manitoba community, and in turn receive an incentive stipend. In 2018, an unpublished survey of the 94 grads of the program, demonstrated that 74% are working in rural and northern Canada. Since the development of the Northern Remote Family Medicine Residency Stream, there is an increasing number of skilled practitioners wanting to work in these environments. Ongomiizwin -Health Services developed a Physician Charter that outlines the vision, values, expectations and commitment of our community of practice [18]. All of the 70 family physicians who work in First Nations communities connected to Ongomiizwin are required to sign and adhere to the charter as part of the contracting process.
A review of internal HR data at Ongomiizwin -Health Services has shown a steady increase in the number of physicians expressing a desire to work in rural and remote Indigenous communities in Manitoba. In 2010, there was a 60% vacancy rate for physician positions in the communities served by OHS with the average length of retention of our physicians in one community at 10 months. In 2017, there was a 5% vacancy rate for physician positions in the communities served by OHS and the average length of retention for physicians with OHS has reached 3.5 years. In part, this may be attributed to an increasing number of appropriately skilled physicians available and interested in Indigenous Health and northern practice. A concerted effort to build team clinicians with shared values; and a focused effort on community engagement with encouragement and support for building community partnerships focused on advocacy in health and health care.

Conclusion
At the heart of our success in relationship building across all sectors has been the growing awareness of the harms of colonisation, of the value of Indigenous selfdetermination, and the subsequent partner relationships with communities and equitable engagement by all five health partnersgovernment, health care administration and providers, academia and community. The ability to develop curriculum that supports learning and accountability, the clinical training and the high level of expertise gained in our residency programs has seen an emerging interest in all partners in "being part of the change". Success in recruitment and retention of physicians has resulted due to an alignment of our physician training programs with our vision for health services in Indigenous communities to honour self-determination and to value Indigenous epistemologies as critical to health and healing.

Disclosure statement
No potential conflict of interest was reported by the authors.