Building Indigenous primary health care infrastructure in Canada: A retrospective comparative policy analysis of Alberta and Ontario.

BACKGROUND: Indigenous primary health care (PHC) in Canada is shaped by complex governance, funding, and jurisdictional arrangements, but how these arrangements shape the development of Indigenous PHC infrastructure remains poorly understood. OBJECTIVE: To examine how historical institutional arrangements have shaped the development of Indigenous PHC infrastructure in Alberta and Ontario over time. METHODS: We conducted a retrospective comparative policy analysis of 89 national and provincial policy documents from 1989 to 2024. Analysis combined deductive application of the Policy Triangle and Indigeneity-Grounded Analysis frameworks with inductive comparative analysis to identify institutional trajectories and domains of Indigenous PHC infrastructure. RESULTS: Distinct institutional trajectories emerged. In Ontario, early and sustained policy action institutionalized Indigenous-governed organizational models through global funding, legislative recognition, and cross-jurisdictional agreements, creating stronger conditions for coordinated infrastructure development. In Alberta, Indigenous PHC initiatives were introduced incrementally within predominantly physician-centred and fragmented funding arrangements, thereby limiting the formalization of Indigenous governance and constraining long-term infrastructure planning. Although both provinces committed to Indigenous PHC, differences in how these commitments were translated into governance, funding, and jurisdictional arrangements produced divergent pathways for building Indigenous PHC infrastructure. CONCLUSIONS: This study demonstrates how historical institutional arrangements have shaped Indigenous-led PHC models. By identifying how policy trajectories influence structural conditions, this study provides evidence to inform Indigenous PHC reform that advances Indigenous self-determination and strengthens health system infrastructure. Findings offer a framework to inform Indigenous PHC reform and comparative policy learning across jurisdictions.