In the Spirit of Partnership and Collaboration: Tribal and State Relations in Support of Public Health Accreditation
Public health emergencies are on the rise in the United States.Concern for communities and loved ones has increased in the wake of hurricanes, H1N1 (influenza) pandemic, acts of terrorism and exposure to chemicals, such as radiation. No other group of people was more adversely affected by the 2009 H1N1 pandemic than our Tribal communities. During April 15 and November 13, 2009, American Indian/Alaska Native people in 12 states had an H1N1 mortality rate four times higher than persons in all other racial/ethnic populations combined.[i] Some possible explanations for this disparity were attributed to the high prevalence of chronic conditions, poverty and delayed access to care. Funding for H1N1 response planning was distributed by the US Department of Health and Human Services (HHS) directly to states. Tribal hospitals and the Indian Health Service were unable to apply for the funding directly from HHS, but, were eligible to receive funds and vaccines through their state. This extra layer of bureaucracy required additional coordination and caused unnecessary delays in getting the appropriate care to Tribal communities. The 2009 H1N1 pandemic is an excellent, and unfortunate, example of how critical Tribal and state relations are. It can be a matter of life and death.
Background:
There are 565 federally recognized Tribes in the United States, each with a distinct language, culture, and governance structure. Native American Tribes are inherently sovereign and maintain a unique government-to-government relationship with the federal government, as established historically and legally by the U.S. Constitution, Supreme Court decisions, treaties, and legislation. Treaties signed by Tribes and the federal government established a trust responsibility in which Tribes ceded land and natural resources in exchange for education, healthcare, and other services.
As sovereign nations, Tribes are increasingly involved in public health activities, regulation and service delivery, alone and in partnership with others. Tribal Health Departments have a vested interest in providing valuable public health services to the communities they serve. In 1975, Public Law 93-638, the Indian Self-Determination and Educational Assistance Act, provided the authority to Tribes to enter into contracts or compacts with the federal government to administer the health programs previously managed by the Indian Health Service.
The Indian Health Service (IHS), an agency within the HHS, has delivered healthcare to American Indians and Alaska Natives since 1955. A function of the federal trust responsibility, IHS is a comprehensive, primary health care system for approximately 1.6 million of the nation’s estimated 2.6 million American Indians and Alaska Natives (AI/AN)[1]. IHS is the only agency within HHS that provides direct patient care. Service delivery includes some public health services and is provided in direct care hospitals and clinics (service units), located on or near Indian reservations, that are operated and managed by the federal government or by Tribes that have assumed the management of their local facilities.
Today. Tribal public health systems are complex and comprised of various stakeholders, including other Tribal health departments, IHS, Area Indian Health Boards, Tribal epidemiology centers, and local and state health departments, among others. Tribal health departments are diverse in terms of their governance structures, organizational infrastructure, and how they coordinate public health services. The nature and extent to which Tribes partner and coordinate services with other public health entities varies by Tribe, region, and type of service or activity.
NIHB’s 2010 National Tribal Public Health Profile
To better understand the nature of Tribal public health systems, the National Indian Health Board (NIHB) conducted a national Tribal public health capacity assessment based on similar assessments conducted by the National Association of City and County Health Officials and the Association of State and Territorial Health Officials. A total 197 Tribal health departments were identified and of those 44 percent participated in the assessment. Tribal consortia and health corporations in Alaska and California counted as a single health department even though they represent multiple Tribes. The assessment was conducted using a web-based survey that collected information on the provision of public health services by Tribes, IHS and other stakeholders; community involvement; Tribal health policy and regulation; program evaluation and quality improvement; and partnerships among local, state, federal and Tribal entities. Assessment results are reported in the 2010 NIHB Tribal Public Health Profile, which is the first national snapshot of Tribal public health systems to be made publically available. Visit the NIHB website to access the profile:
The Tribal public health capacity assessment explored a broad spectrum of public health activities, including epidemiology and surveillance, immunizations, screening, maternal and child health and prevention, among others. When Tribal health department administrators were asked to indicate which entity(ies) provide specific public health services in their community, nearly fifty percent of Tribal health administrators indicated that state and local health departments provide epidemiological and surveillance services for communicable and infectious disease. About twenty percent reported state and local behavioral services, surveillance on behavior risk factors and environmental health, child immunizations, HIV/AIDS and sexually transmitted disease screenings, hazardous material response, and tobacco prevention are prrovided. Nearly thirty percent reported that local health departments provide maternal and child health services, including family planning, prenatal care, Women, Infant and Children services, and well child clinic.
Tribal/State/Local Relations
It is clear and local and state health departments are important partners in providing public health services in Tribal communities. The extent to which Tribes partner with other public health entities varies by Tribe, state, and type of service. Presidential Executive Order 13175 Consultation and Coordination with Indian Tribal Governments requires regular and meaningful consultation and collaboration between the federal government and tribal officials on significant policy and funding decisions that have tribal implications. However, when the federal government transfers responsibility and funding for public health functions to states, such as block grants, tribal consultation at the state level is not routinely accomplished. Public health accreditation may provide opportunities for improvement in communication, partnership and collaboration among tribal, local and state health departments.
Tribal/state relations vary based on history, policy, relationships with key stakeholders, and the level of knowledge and understanding of tribal sovereignty, among others. Some of the primary challenges a briefly summarized below:
- Overlapping jurisdictions. Tribal lands oftenoverlap or are adjacent to multiple local and state jurisdictions. The relationship a tribe has with each jurisdiction may impact the level, quality, and consistency of public health activities conducted across the community.
- Authority and responsibility. Challenges arise around jurisdictional authority related to public health activities such as public health law enforcement, outbreak investigation, service provision and others. There may be difficulties in reaching agreement among tribal, state and local governments and agencies about who has authority and responsibility to employ a specific public health activity.
- Federal funding allocated to states for its citizens, including tribal members. Federal funding is often allocated to states in the form of block grants. Typically, funding allocations are based on population and need. Examples include, but are not limited to, emergency planning and maternal and child health. While the formulas for these block grants take into account American Indian and Alaska Native populations, these funds may or may not be disseminated equitably or consistently to Tribes located within a given state.
Tribal, federal and state relations may be further complicated by other federal legislation or policy. For example, in 1953, during a time of termination and forced assimilation, the federal governmenttransferred the majority of its legal authority (jurisdiction) to state governmentsunder Public Law 280 (P.L. 280). The six states included in P.L. 280 are Alaska, California, Minnesota, Nebraska, Oregon and Wisconsin, where more than half of federally recognized Tribes are located. [need a statement to describe how this impacts tribal sovereignty and health]
Coordinated Public Health Activities and Accreditation:
The Public Health Accreditation Board (PHAB) is a non-profit, non-governmental organization that is the accrediting body for national public health accreditation. The goal of accreditation is to improve and protect the health of every community by advancing the quality and performance of public health departments (Tribal, state, local, and territorial). National public health department accreditation consists of a set of standards by which to measure performance and recognize those departments that meet the standards. Accreditation provides a means for identifying and prioritizing improvement opportunities, enhance management, and strengthen relationships among Tribal public health system partners, including state and local health departments.
Collaboration and coordination among Tribal, state and local health departments will be critical to those seeking accreditation. The importance of conducting,or participating in, a collaborative process that results in a comprehensive community health assessment, which is one of three prerequisites to apply for public health accreditation.Domain 1, Standard 1.1 of the PHAB Standards and Measures explains that community health assessments describe the health status of the population, identify areas for health improvement, determine factors that contribute to health issues, and identify assets and resources that can be mobilized to address population health improvement.[ii] Documentation is required to demonstrate participation among representatives of the various sectors of the Tribal community. Given that local and state health departments often have a role, whether minimal or significant, in providing or collaborating to provide important public health activities, collaborating on a community health assessment can be a starting point for building or strengthening a foundation for community health improvement planning and coordinating public health services.
Emergency preparedness and planning is another area where coordination and collaboration are critical. Among the Tribal health departments that participated in the NIHB public health capacity assessment, less than 40 percent receive funds from their state agency/department though the CDC Public Health Preparedness Cooperative Agreement. Of those that do not receive funds, 77 percent participate in a task force or coalition of community partners that is led by another agency to develop and maintain emergency preparedness and response plans. This is a critical issue for Tribal health departments seeking accreditation as the will be required to demonstrate measures related to maintaining 24/7 surveillance systems, reporting, staff training, and communications. It is also critical for state and local health departments who will need to demonstrate that tribal jurisdictions are included in their planning, communications and response. Good will is not enough when sources of funding are disseminated to some jurisdictions and not others. Until the federal government funds Tribes directly, Tribes will continue to rely on the states to provide adequate funding to address these issues. This is true for all federal block grant programs, not just emergency preparedness.
One of the most efficient ways, as provided in the PHAB Standards and Measures, for documenting coordinated public health activities and services is through memoranda of understanding or agreement (MOU/MOA). MOU/MOAs serve as means for formalizing partnerships, defining jurisdiction authority and responsibility, roles and responsibilities in providing specific services, and data sharing. Establishing MOU/MOAs is time consuming and labor intensive, and require a fair amount of negotiation and approval at multiple levels within each Tribal, state and/or local government and their agency. Regardless of the bureaucratic processes that may exist within each governmental entity, documentation of coordinated efforts may be required in a number of areas, including, but not limited to, collecting and maintaining reliable, comparable and valid data related to population health (standard 1.2) conducting timely investigations (standard 2.1), conducting a comprehensive planning process resulting in a tribal/state/community health improvement plan (standards 5.2) and conducting and monitoring public health enforcement activities (standard 6.3).
NIHB Recommendations:
While many challenges lie ahead in strengthen Tribal, state and local government relations, there are also a number of opportunities. Public health accreditation challenges all health departments to work together to ensure that all people, regardless of where they live, they[AH1] can expect the same standard of public health activity. Cross-jurisdictional technical assistance and training can generate greater understanding, communication and awareness of the public health needs and assets, and the sharing of best practices. Tribal/State summits and roundtables are an excellent way to identify issues and develop strategies to address them. The federal model for Tribal consultation is being adapted by more and more states as a means for improving Tribal/state relations. Arizona, New Mexico, Wisconsin and California are just a few examples of states that have developed more formal means for engaging in Tribal consultation. Relationships take time to build and must be fostered on an ongoing basis. Like the public health accreditation process, it is ongoing and provides an opportunity for continuous quality improvement in an effort to improve community health.
TOPIC: Tribe/State Relations
1
[1] U.S. Department of Health and Human Services, Indian Health Service. Trends in Indian Health. Washington, DC: Indian Health Service; 2002-2003.
[i]Centers for Disease Control and Prevention. “Deaths related to 2009 Pandemic Influenza A (H1N1) American Indian/Alaska Natives --- 12 States, 2009. Morbidity and Mortality Weekly Report, December 11, 2009/58(48): 1341-1344. Accessed July 27, 2011.
[ii]Public Health Accreditation Board. “Standards and Measures, Version 1.0”. Approved May 2011. Accessed August 4, 2011.
[AH1]We need to find out if this is the best way to frame this statement since it is based on some of NACCHO’s earlier work.