In terms of program management, the information gathered from the literature indicates that one of the most pressing problems encountered by Tribes operating health programs is difficulty in recruitment and retention of professional staff. In a 1997 survey of approximately 210 Tribes conducted by the National Indian Health Board (NIHB, 1998), approximately 75 percent of responding Tribes that operated their own health programs indicated that they experienced difficulty in recruiting physicians and 40 percent reported difficulty in recruiting mid-level practitioners. In contrast, of respondents affiliated with IHS direct service programs, 67 percent reported that recruitment of physicians and 25 percent reported that recruitment of mid-level practitioners was a problem. Interestingly, Tribes operating their own health programs were less likely than IHS direct service Tribes to report difficulty in recruiting other types of health professionals, such as nurses, pharmacists and dentists.
Little is known about the impact of Tribal contracting or compacting on access to health facilities, providers, and services. There are limited data to suggest that access to some programs may be reduced, while access to other services or programs may actually increase. For example, in the 1997 NHIB survey, 16 percent of compacting Tribes and 32 percent of contracting Tribes indicated that they had eliminated programs during the previous 3-year period. In contrast, 38 percent of IHS health directors responding to this survey indicated that they had eliminated programs during the same time period.
Over the same period, a significant number of contracting/compacting Tribes reported having added services, including:
- One-quarter reported adding mental health services, compared to 14 percent of IHS health directors;
- One-fifth reported that they added alcohol treatment services, compared to 5 percent of IHS health directors who reported adding substance abuse services; and
- Nearly one-quarter reported adding dental services, compared to.10 percent of IHS health directors.
Interestingly, Tribally-managed programs were less likely than IHS programs to have added services for diabetes care. Only 12 percent of health directors of Tribally-managed programs indicated that diabetes care services had been added, compared to nearly 30 percent of respondents from IHS direct service programs.
Although the literature indicates that Tribes either perceive that contract funding is inadequate or are financially struggling to administer health programs (National Indian Health Board, 1998; Noren et al., 1998; GAO 1998) there is little evidence to indicate how access to services may be affected by financial concerns. In the NIHB survey, 20 percent of respondents from Tribally-managed programs indicated that they had to close health facilities; however, less that one-half of these respondents indicated that the closure was related to funding problems. In fact, only 4 percent of Tribes ceased management of health programs altogether. While insufficient budgets were cited as a reason for terminating their participation in contracting/compacting, geographic barriers and regulatory factors were also mentioned as reasons for this decision.
The 1998 GAO study of Tribally-managed health services in Alaska also concluded that service availability was generally unaffected when a community takes over health services from a regional health organization (RHO). RHOs are non-profit entities that contract with the IHS to manage and deliver health services to a Tribe. Instead of having the RHO manage their health service delivery, several Alaska Native communities have chosen to directly contract with the IHS. In transitioning to community control, some service disruptions were noted; however, because contracts between the IHS and communities were generally limited to a narrow set of services (typically alcohol abuse and mental health services, health education and non-physician services), the impact on the community was thought to be minimal. Moreover, since contracts are generally program transfers, where the community takes over from the IHS or RHO the management responsibility for existing services, staffing and services are often unchanged. The GAO cautioned that the availability of contract managed health services, which tend to have higher administrative and indirect costs, may be compromised in the future if funding for contract support services is reduced. (Contract support funds refer to the reasonable costs reimbursed by IHS to Tribal communities to cover contract compliance and program management activities.)