Evaluation of Tribal self-governance and Tribal management of IHS health program should be considered in the context of the funding limitations facing all IHS funded health programs. Between 1989 and 1998, real per capita IHS spending declined by nearly 20 percent.(4) Similarly, the Indian Health Service estimates that between 1991 and 2001, real per capita expenditures for personal health care decreased by 14 percent - from $1,349 in 1991 to $1,157 in 2001. (5) The "Level of Need Funded (LNF) Study: Research to Estimate Costs of a Mainstream Health Benefits Package for Indian People" (November 1999) reports that, in 1999, personal health care spending for AI/ANs who received services from the Indian Health Service was only 55 percent of the level of need.
The significant under-funding of the Indian Health Service makes evaluation of Tribal management of health programs more difficult than most evaluations. When Tribes take over management of health programs, they do so with inadequate resources from IHS to meet the needs of Tribal members and must immediately assess priorities and develop strategies either to ration care or to obtain additional sources of revenues to provide services. Because Tribes are dependent, for the majority of their revenues, on the IHS, their performance under self-governance may be affected by real declines in the IHS budget. This factor should be taken into account in any evaluation of Tribal management of health programs.