Canada’s latest auditor general’s report reveals an uncomfortable truth: billions of dollars and countless commitments later, the federal government still cannot demonstrate meaningful improvement in health services for First Nations.

As a family physician working in my First Nation, Tyendinaga Mohawk Territory in southern Ontario, I see the evidence of this failure not in spreadsheets but in people — patients navigating a health system that remains structurally unequal.

Nearly 10 years after the Truth and Reconciliation Commission’s (TRC) Calls to Action, it is clear that reconciliation without accountability delivers only rhetoric, not care.

The report states:

“Increasing First Nations’ capacity to deliver programs and services within their communities is critical to improving outcomes for First Nations people and supporting reconciliation.”

Yet the same report concludes that the department has taken a “passive and siloed approach” to supporting First Nations. It found unsatisfactory progress on five of 11 recommendations first issued in 2015 regarding access to health services for remote communities.

Encountering racism

A decade later, systemic barriers remain — geography may vary, but inequity is consistent.

Even in communities like mine, which sit within driving distance of tertiary care, accessing culturally safe services is far from guaranteed.

Patients still encounter racism in hospitals and clinics. Providers still rotate through Indigenous communities rather than build lasting relationships. And families still find themselves falling through the cracks between federal and provincial systems that debate who pays instead of who helps.

The auditor general’s report acknowledges some progress — more nurse practitioners and paramedics working in First Nations communities — but the average monthly vacancy rate remains 21 per cent. Constant turnover and short-term contracts erode trust, continuity and quality of care.

The auditor general also found no satisfactory progress on any previous recommendations to ensure that First Nations communities have ongoing access to safe drinking water. Clean water is the most basic determinant of health, yet its absence continues to expose the limits of Canada’s political will.

A decade later, inequity remains

The TRC Calls to Action related to health — numbers 18 through 24 — called for eliminating inequities, recognizing Indigenous healing practices, increasing Indigenous professionals in health care and ensuring Indigenous leadership in governance.

But the Yellowhead Institute’s September 2025 report, Braiding Accountability, shows that Canada remains mired in performative progress. Institutions have reached the “strengthen” phase — hiring Indigenous staff or creating advisory councils — but rarely the “change” phase, where Indigenous Nations co-develop priorities, indicators and accountability measures.

Under Call 19, the report notes, the goal of measurable progress toward health equity is undermined by the “absence of Indigenous data sovereignty.” Instead, “institutions report on activities, not results, using settler-defined metrics that obscure ongoing inequities.”

As a medical educator, I see this mirrored in our training systems. Under Call 23, governments were urged to increase Indigenous representation in health professions.

Yet, Braiding Accountability points to ongoing gaps in representation and a lack of meaningful data on whether Indigenous professionals are actually being retained or advancing into leadership. It notes that recruitment efforts often amount to a revolving door: institutions bring Indigenous staff into environments that remain unwelcoming, and then attribute their departures to supposed cultural issues rather than addressing the systemic problems that drove them away.

And perhaps the sharpest critique of all: Failing to shift authority and decision-making to Indigenous communities simply continues the very colonial dynamics that made the push for Indigenous health professionals necessary in the first place.

At Queen’s, through the Queen’s-Weeneebayko Health Education Program — which I lead — we are trying to do things differently by building pathways for Indigenous learners to study in their own regions, guided by Indigenous leadership and values.

The goal of this program is to transform who holds power in the health system.

A moment of possibility

There is, however, a reason for cautious optimism. With recent cabinet appointments, Canada now has its first Indigenous minister of Indigenous Services Canada (ISC). Mandy Gull-Masty’s appointment represents the first time an Indigenous woman leads the very department responsible for addressing these systemic failures.

Her lived experience as an Indigenous woman positions her to see what others have not: that reconciliation cannot be achieved through bureaucratic procedure, but through the transfer of decision-making power to Indigenous governments and communities.

Real progress will mean dismantling silos, resourcing First Nations to design and deliver their own health systems and holding all levels of government accountable to measurable outcomes.

It will mean embedding Indigenous data sovereignty and governance into every facet of health planning so Indigenous Peoples can finally define what success looks like on their own terms.

The human cost — and the hope

Every audit finding has a face. For me, it’s the patient who avoids seeking hospital care after a racist encounter, the Elder who still boils her water each morning and the young Indigenous medical student who tells me she wonders if she truly belongs.

These stories are a reminder that inequity does not end where the roads begin. Reconciliation will never be achieved through rhetoric or reports alone. It demands courage — the courage to transfer power, to embrace accountability and to care enough to change.

The appointment of an Indigenous minister offers a moment of possibility. If Gull-Masty can insist that reconciliation be measured in lives improved, systems restructured and trust rebuilt, then perhaps Canada will see real transformation.

This article is republished from The Conversation, a nonprofit, independent news organization bringing you facts and trustworthy analysis to help you make sense of our complex world. It was written by: Jamaica Cass, Queen's University, Ontario

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Jamaica Cass works for Queen's University. She receives funding from the National Circle on Indigenous Medical Education, the CPFC and the CMA. She is a board member of the Indigenous Physicians' Association of Canada and the Medical Council of Canada.