The Literature Review was conducted to provide a foundation for the development of the evaluation issues and related data requirements to guide the design of the feasibility study. The objectives of the literature review included:
- Identification of existing studies and evaluations of Tribal Self-Governance and/or Tribal management of health and social service programs;
- Identification of data limitations and other factors that pose barriers to conducting comprehensive evaluations of Self-Governance and Tribal management of health and social service programs.
- Review of the methodologies and data sources used in previous studies, in order to assess both analytic rigor and the extent to which the findings are of general application;
- Synthesis of available evidence and findings from existing studies; and
- Assessment of the implications of these findings for the Tribal Self-Governance Evaluation Feasibility Study.
Tribal Self-Governance of Indian Health Service programs have been in place for a decade and extensive detailed data are submitted by Self-Governance Tribes to IHS. These data would make it possible to conduct a quantitative evaluation of Indian Health Service programs managed by Tribes under Self-Governance. The evaluations of Self-Governance of IHS programs that have been conducted to date, however, have been primarily qualitative. There has been limited evaluation of other programs managed by Tribes under either Self-Governance or under contracts and grants.
Most of the studies identified that have evaluated Self-Governance or Tribal management of health or social programs employ qualitative techniques, such as key informant interviews, which rely on stakeholders’ perceptions to reach conclusions about program effectiveness. These qualitative studies provide insight into how various Tribes structure their health and social service programs, the characteristics of Tribal residents participating in these programs, and successes encountered in program implementation. Further, these studies – particularly those that focused on the Tribal Temporary Assistance to Needy Families program – effectively highlight how social and economic conditions on Reservations, such as the high rate of poverty, high unemployment rates, and the lack of an economic base, may pose substantial barriers to achieving the intended goals of these programs. These studies do not, however, provide definitive quantitative evidence on the extent to which and how Tribally-managed health and social service programs have operated to better meet the needs of their members. Most studies do not incorporate a comparison group in their design and, therefore, it is not possible to determine how persons participating in Tribal programs fare compared to how they would have fared if control over these programs were still vested with the Federal or State government.
Previous research on process, structure, and impacts of Tribal management of health and social services is limited in major ways: 1) many of the programs that are currently managed by Tribes have not been in existence for a sufficient time to permit an assessment of the longer-term effects and effectiveness of Tribal management; 2) Tribes are unique in cultural, socioeconomic, and geographic circumstances and, as a result, successful program structures and effectiveness may also be unique and not useful to other Tribes or other Federal grantees; and 3) adequate and comparable data across Tribally-managed programs and between Tribally-managed programs and Federal and State managed programs are not available.
Given these findings, a primary focus of the Evaluation Feasibility Study was to review and identify potential sources of data that would be adequate to permit a quantitative evaluation of relevant issues.