This thesis investigates how the governments of Canada, Australia and New Zealand balance the ideal of indigenous self-determination with other pressures, such as current trends in public administration and accountability, pressures on the health care system, issues of and sensitivities around minority rights, equity in health and cost-efficiency. It is based on four case studies conducted in Australia and New Zealand. The Canadian material is drawn from both the literature and a period of twelve years working in indigenous-controlled health services. All three governments have made some policy commitments to increased indigenous participation and self-determination, in the pursuit of health gains. The goal is a more responsive health care system. Self-determination is often mentioned. In Australia and New Zealand, the commitment extends to primary, secondary and tertiary care. Canada focuses exclusively on improving the responsiveness of on-reserve primary health care services. The contractual environment in which providers operate bears a highly nuanced resemblance to official policies. Two broad categories of contractual environments have emerged. Indigenous providers who operate in an environment where the funder is an indigenous-specific government authority (First Nations and Australia's new PHCAP program) have access to a relational contractual environment that is advantageous administratively, financially and in terms of comprehensiveness of services. Indigenous providers that secure funding from non-indigenous specific funders (New Zealand, and Australian Aboriginal Health Services) operate in a classic contractual environment where funding is accessed via a multiplicity of fragmented, often proposal-driven, contracts with high administrative costs. Classic contractual environments lead to a patchwork approach to achieving health gains. Indigenous aspirations for self-determination have been partially satisfied with increased opportunities for contracting in health. Although the link between increased indigenous participation and improved outcomes remains to be explored analytically, it is doubtful that classical contractual environments can yield the health gains expected.