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APHA Presentation on the IHS Reorganization

                         DISPLAY SLIDE I:
                     Reinventing Government
	A Qualitative Inquiry into the Decision Making Process

Good morning.  I’d like to first thank APHA for giving me the 
opportunity to present this paper.  This paper reflects some of the
preliminary work that I’ve done in preparing my dissertation. 

As most of you know, the Indian Health Service is currently under a 
process of reorganization.  This process is timely in light of the 
push to "reinvent" government into a more effective and efficient 
entity.  In recent times, much has been said about the role that 
government should play in delivering services to the people.  Health 
care is an area of government that is under continual scrutiny.  The 
explosion of public expenditures on health care following the 
introduction of Medicare and Medicaid led to the emergence of cost 
containment as an independent policy objective.  At the same time, 
government agencies have been challenged to adequately perform the 
social functions that they were designed to perform while confronting
the constraints of shrinking budgets. 

Currently, the Indian Health Service is the primary provider of health 
care in Indian Country.  They are not only the primary provider of 
health services, but also the administrative arm of the government 
here.  As a result of budget constraints and "reinventing government"
ideology, the IHS has become the focus for examining efficiency and 

The subjects of my study are the members of the Indian Health Design 
Team, or IHDT.  They are the people charged with the task of examining
how this bureaucratic agency works, and then to make recommendations 
on ways to improve performance.  My research project will conduct face
-to-face interviews with selected members of the 28 decision makers 
of the IHDT. The make up of this team is a cross section of key 
players in the Indian health care community. Of the twenty eight 
members, 22 of them are not employees of the IHS. This is significant
in itself for in the language of reinventing government, the people
who are the beneficiaries of government programs should be the ones
that have a say in what those benefits should be.  Those outside of 
government should be involved in government.  

While the specific purpose of my thesis is to follow the restructuring
process of the Indian Health service, I find it first necessary to 
examine the context in which these processes are taking place.  So it 
seems that as the first speaker this morning, I should give an 
overview of what the IHS is about.  I feel that the contexts in which 
decisions and programs are created are extremely important …that the 
IHS is truly unique and that the call for change in Indian country 
must be answered with the ideas and solutions that reflect this unique

I would like to highlight some key terms here.  Let me put these up 
for you to gaze upon.

                           DISPLAY SLIDE II
       KEY TERMS:

While concerns over escalation of costs and diminishing appropriation
should be reason enough to study this restructuring process, the more 
salient issue should be that of health status outcome. Will 
recommended changes to control costs, (or cost efficiency) result in
better health outcomes, (or cost effectiveness)?  Both ends of this 
question are goals that the IHS must address if it is to carry out the
social function that it was designed to perform.  And so, the Indian
Health Service is restructuring in order to find that equilibrium in
this challenging environment.  At the beginning of this year, the IHDT
presented its recommendations to the IHS.  The recommendations of the 
IHDT has plainly stated that in order to accomplish those goals, the
current IHS structure needs to be dismantled and reorganized.

One observation is that "the problem with the current system is that 
public officials cannot use common sense and good judgment in ways 
that would promote better…performance".  There is a feeling that the
current bureaucratic structures are not able to perform the social 
functions that they were intended to do. 

The belief that the way in which the current system operates is 
inadequate reflects a finding of the 1989 Volcker Commission Report.

         Control through multitudes of regulations and procedures, 
         administered by a central agency removed from service 
         delivery, has created managers with limited power but full 
         responsibility for any problems that occur.  

The IHDT recommendations echo findings of the 1993 Winter Commission 
report which stated that the "pattern and the problems are clear.  
The face of America outside government is changing faster than the 
face of the work force inside. " 

Taking all of the above into consideration, this became an animating 
theme of Vice President Al Gore’s 1993 report,the National Performance
Review, OR NPR.  In here, the four goals of cutting red tape, putting 
customers first, empowering employees in a results-oriented environment 
and getting back to basics are enunciated.

The Indian Health Design Team met for the first time in October 1994,
shortly after Vice President Gore’s report.  The resulting 
recommendations that they made for redesigning the Indian Health 
Service clearly reflect the language of  "reinventing" government.  

So if it is to be "reinvented", then let’s take a look at what it is 

The Indian Health Service (IHS) is a bureau within the Public Health 
Service, formed in 1954 by a transfer of health services from the 
Office of Indian Affairs (PL83-568)). 

In the subsequent 40 years, IHS has grown larger and more complicated 
and has become a truly complex national organization that is 
responsible for direct and contract health care services to approxi-
mately 1.4 million Indian people.  Unlike other "minority" groups, the
relationship between the Indian tribes and the federal government is a
government-to-government one.  Provision of health care services by 
IHS is based on various treaties signed in the 18th and 19th century, 
whereby Indians ceded lands to the US in trade for these and other 

                        DISPLAY SLIDE III
	(an organizational chart is displayed here.  I was
         unable to duplicate it on html. sorry)

Organizationally, the headquarter office is located in Rockville, 
Maryland. There are three entities on the next level of the 
organizational chart.  First, there are 12 IHS administrative Area 
Offices located regionally throughout the United States.  Within each
Area jurisdiction are Service Units which consist of hospitals and
Health Centers.  While these made up most of the traditional delivery 
system, there has been a shift toward Tribally run units.  These were 
the result of the 1975 Self-Determination Act. which allowed Tribes 
the option of managing and operating IHS programs in their communities
on a  contractual basis.   These were normally set up within tribal 
geographical boundaries (or reservations).  As Indians moved off the 
reservation and into the cities, there was a need for Urban Units.  
Urban units did not own hospitals, but contacted with other existing 
providers for service.

The Indian Health Service budget is authorized and appropriated 
through Congress.  It has increased 135 percent from 1986 to 1995. 
The appropriated amount for FY 1995 was $2.1 billion.

So, has it been effective?

When IHS was transferred to the Public Health service from the 
Department of the Interior in 1955, mortality and morbidity rates for 
the Indian populations lagged far behind that of the general US 
population.  As a result of IHS programs and advancements in medicine,
many of the health indicators of this population have improved.  Life 
expectancy at birth, age at death, maternal and child health and 
infectious diseases have all been affected positively.  In the areas 
of infant mortality, maternal death rates, gastrointestinal disease 
and tuberculosis, the dramatic improvements for these areas far exceed
those for the general population for this time period, and it is 
important to note that they have attained parity with health status of
the rest of the nation.


             Alcoholism - 447 percent greater
   	     Tuberculosis - 340 percent greater
	     Unintentional Injuries - 168 percent greater
	     Diabetes Mellitus - 154 percent greater
	     Suicide - 42 percent greater
             Homicide - 34 percent greater 

Like the general US population, the causes for death and morbidity in
the Indian population has shifted away from acute causes and toward 
chronic disease and behavioral impairments.  While this is not a 
significant distinction by itself, the age-adjusted mortality rates 
for many of these conditions illustrate a different picture between 
the health status of Indian and US populations.  (look at slide)

A comparison of Indian rates to general US for these conditions 
illustrate enormous disparities between the populations.  Most 
strategies to address these conditions parallel domains of public 
health rather than direct medical service.  In the area of infectious
diseases, (pause) adequate housing, sanitation, water supply, …are 
seen as the key to reducing these diseases.  For injury prevention 
and chronic disease, community awareness/empowerment, health promotion
, early screening and better surveillance systems are seen as the
basic building blocks. At the same time, there is a need for some 
basic and acute medical services that are taken for granted off the 

				Expressed in Percentages		
TYPE INSURANCE	       U.S.	Wht	Blk	Hisp		SAIAN
Private			75	81	53	50		 28
Public Only (not IHS)	10	 7	25	18		 17
Uninsured/IHS only	16	12	22	32		 55

How important is the IHS to the Indian population as far as creating 
access to health services?  Findings from the Survey of American 
Indians and Alaska Natives (SAIAN) disclose that in 1987, Indians had
less private insurance coverage than any other ethnic group.  Notice
that over half of the Indian population depends on IHS services as 
its sole provider.

	(cunningham et al write)
	The generally low socioeconomic status of this population 
        along with relatively low rates of private insurance suggests 
        that few have the means to obtain health care other than what 
        is provided free of charge from the Indian Health Services.  
        For most of this population, a facility owned or operated by 
        the Indian Health Service or a tribe is the usual source for 

A trend that is occurring is that the Tribes are taking a more active
role in the provision of these health services.  In fact, the premise
of local control is an animating theme of the IHDT recommendations.  
I started this discourse by posing the question of whether 
reorganization would lead to not only more cost efficiency, BUT also 
more cost effectiveness. That is, will the changes improve the health 
status of Indians.  After all, that is the mission of the IHS.

A retrospective study (1973-1986) was conducted to assess health 
status amongst the three tribes, Umatilla, Cayuse, and Walla Walla, 
that make up the confederation of Umatilla Tribes in Washington state.
A common data set available to the researchers was prenatal care in 
1st trimester (prevention strategy) and low birth weight babies 
(outcome).  Because these indicators are also used to asses general 
population, they provided a valid comparison group.  Their 
relationship to national objectives was used as a point of reference.
From an historical perspective, in the 1960’s, all medical services 
in the Confederation was performed on a contractual basis.  Public 
health issues, the main focus of IHS during this time period were also
contracted out to county health departments.  In the 1970’s, tribal 
control was exercised over many of these services and a hospital was
built under the auspices of the Indian Self-Determination Act. A more
active role was then taken on by the tribes.  


Indicator   1990 Objtve		1973-1976	1984-1986
LBW		< 5%		 5.8(6.1)	 4.1   (5.0)
PN care		>90%		42.3 63.9)	62.6  (65.7)
InPts 			      	 1,290	 	 1,832
Outpts			  	   709		12,710			

LBW stands for Low birth weight.  The 1990 objective was to be less 
than 5%.  In the period 1973 to 1976, the percentage of LBW babies 
born in the Umatilla Confederation was 5.8 percent.  The number in 
the parentheses is the percent of babies born in that same 
geographical area that were not part of the IHS system.  Note than in 
the period 1984 to 1986, after Tribal control was exercised, the less
than 5% goal was met by both the IHS and the non-IHS population. 
Although the objective of having 90% of all mothers seeking prenatal
care in the first trimester did not meet the more than 90% objective, 
note that prenatal service usage increased substantially in the IHS 
population.  The overall increase in utilization for outpatient 
services is the most dramatic finding for this study.  Culturally 
more sensitive?  Possibly,  More efficient?  Probably. More effective? 

Where do we stand today?

I have described the Indian Health Services as it existed prior to 
implementation of any of the IHDT recommendations. As of July 1997,
many of the recommendations have already begun.  Phase I of the 
recommendations was to reduce headquarter size. The IHS headquarters 
has reduced its nine major offices down to three.  One hundred 
forty-five sub-organizational units have been consolidated into 
forty units.  In 1993, there were 900 employees at the headquarter 
and regional level.  In 1997, there are approximately 475.  The next
phase of the restructuring will occur at the Regional level where 
there are 12 administrative units.

What have we learned so far?  What are the lessons from reinventing 
government?  Why is this attempt at reorganization continuing when 
others such as a the restructuring of the Bureau of Indian Affairs

The first formal meeting of the IHDT was in October of 1994.  While 
the IHS laid out its plans to restructure under the National 
Performance Review guidelines, tribal attendees had these comments to 

ªTribes do not have agendas for reductions.  The Administration’s 
 agenda for reductions is not the agenda of Tribal leaders.

ªThe treaties made with Tribes do not include a responsibility for 
 paying for deficits.

ªResources for Indian health care should be adequate to match the 
 oaths this government made in exchange for millions of acres of land.

ªCredibility for the design will earned if Tribes identify what the 
 Agency is to be.

ªParticipation of elders in the change process is important because 
 of their role in maintaining the family unit.

These comments did come without a recent and powerful precedent.  In 
1990, the Secretary of Interior created a Task Force to study 
reorganization of the BIA.  Its charge was to come up with 
recommendations just like the IHDT.  At that time, this Task Force 
was unique in that it sought full tribal participation in the planning
process.  Like the current IHDT, there was strong Tribal 
representation with 36 of 43 members coming from non-BIA employees.  
Under the auspices of NPR, another plan was created.  While both 
plans agreed that decentralization of government involvement and the 
redistribution of authority to local levels was important, the NPR 
"ignored the work of the Task Force and in fact, failed to involve 
the tribal leadership, even on a consultative basis".

Caleb Shields is Tribal Chairman of the Assiniboine and Sioux Tribes
of the Fort Peck Reservation in Montana.  He was a member not only of
the BIA Task Force but is also a member of the IHDT.  He very 
pointedly questioned the motivation of the NPR recommendations and 
wondered how their plan would benefit Indians.

	(he writes)
while the task force sought 
to improve its performance while meeting the needs of the tribes and 
Indian people, NPR is forcing the reorganization of BIA (and IHS too)
to meet the budgetary commitments of the Administration without 
regard to its impact on BIA performance or the needs of the tribes 
and Indian people.

It was clear that if the federal government was going to solicit 
input from the Tribes to "reinvent" government, it would not be just 
symbolic participation.  The agenda for restructuring was not going 
to be one where the outcome did not fulfill the social function of 
the agency that was designed to deliver it and that less than a full 
partnership in this process was unacceptable.

This message was reinforced when the BIA tried to present its 
reorganization plan to tribal leaders in Billings, Montana three 
months later.  Tribal leaders walked out of the meeting stating that 
the request for their input was "false involvement." One leader said 
"…as far as the consultation process, I feel it’s a done deal.  
Why did you even ask us to come here?" 

So far, I have explained the process of "reinventing government" as
part of a national movement.  I began this description however, by 
stating that the Indian Health Service process was different.  
Unique.  The comments elicited from Tribal leaders make this very 
clear. A governmental agency like the IHS is not a self contained 
entity.  The relationship between the US government and the Indian 
nations is one where separate nations are trying to forge a working 
inter-dependent structure where both can meet their constituent needs
and values.  In doing so, parties must negotiate in the "utmost good

Therefore, this reorganization is about more than just a reshuffling 
of layers of bureaucracy.  It is even more than the consensual goal 
of raising the health status of Indians.  It is a restatement of how 
the Indian nations and the United States government will define their
future relationship. 

An admonition from Eric Bothwell to the IHDT members at the first 
meeting cuts right to the core.  He asks if the recommendations that
they will be making will be merely be cosmetic changes, or whether 
they will be the needed bone surgery.  "The notion that organizational
beauty is only skin deep but organizational ugliness (ineffectiveness)
goes clear to the bone, appears true.  A variety of reasons have been 
identified for this pattern of organization only achieving cosmetic 
surgery, or downsizing to nothing more than a smaller but still 
dysfunctional organization."   He asks that "we [be] better than that!

Time does not permit a thorough discussion of tribal sovereignty, the 
inner workings of bureaucratic behavior or the theoretical 
underpinnings of decision making processes.  However, as I embark on 
the rest of my research, these are some of the awarenesses that I will
bring with me.  The agenda is set.  The implementation is already 
occurring at a structural level.  In the ensuing years, my intent is
to follow not only the implementation process of this grand design, 
but to also scrutinize and evaluate the results of reorganization in 
terms of health status outcome.  Concomitant with that, I expect to 
note, explore and analyze the politics of the US government and the
Indian nations as they strive to negotiate in the "utmost good faith".
As a social researcher, I must maintain a proper academic distance to
my findings, however, as a subjective person living in a time of 
historical significance,  I approach the journey of this research 
with great optimism and faith.  ….and I invite you to come along with 
me on this journey.