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Public Health (2007) 121, 296307

www.elsevierhealth.com/journals/pubh

Original Research

Future public health delivery models for Native

American tribes
M.T. Allisona, P.A. Riversb,, M.D. Fottlerc
a

Native American Liaison, Arizona Department of Health Services, Phoenix, Arizona, USA
Health Management Program, College of Applied Sciences and Arts, Southern Illinois University,
1365 Douglas Drive, Mail Code 6615, Carbondale, IL 62901-6615, USA
c
Health Administration Programs, The University of Central Florida, Department of Health Professions,
College of Health and Public Affairs, Orlando, FL, USA
b

Received 7 April 2006; received in revised form 2 November 2006; accepted 16 November 2006
Available online 7 February 2007

KEYWORDS
Public health professionals;
Access to care;
Native Americans;
Tribes;
Survey

Summary Background: More and more Native American tribes are assuming
control of their own public health care delivery systems by contracting the functions
of the Indian Health Service (IHS) through the provisions of P.L. (public law) 93-638,
the Indian Self-Determination and Education Assistance Act. In doing this, some
Native American tribes are making decisions to create or plan their own departments
of public health. In Arizona, the Gila River Indian Community has already established
its own department of public health and the Navajo Nation is in the planning stages
of establishing its own department of public health.
Methods and results: This paper proposes three public health organizational
delivery models to meet the public health needs of small, medium, and large
Native American tribes. Information for these models was derived from interviews
with officials associated with the Arizona Department of Health Services and leaders
of Native American tribes. These models progress in size and complexity as we move
from small to medium to large tribes.
Conclusions: (a) service delivery should focus on both preventative and curative
services; (b) services should be developed with input from the underserved
population; (c) members of underserved populations should be trained to provide
service to their communities; (d) one model of health service delivery will not be
appropriate for all underserved populations; and (e) different models are required to
respond to differing cultures, populations, and geographic locations.
& 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights
reserved.

Corresponding author. Tel.: +1 618 453 8842; fax: +1 618 453 7020.

E-mail address: privers@siu.edu (P.A. Rivers).

0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2006.11.005

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Public health delivery models for Native American tribes

Introduction
There are 558 federally recognized Native American tribes in the USA, with a combined population
of 2.5 million people (approximately 1.2% of the US
population) of whom about 1 million live on
reservations. The median age of the Native American population is 27.8 years compared with the
overall US median age of 36 years. A comparison of
inter-quartile ranges indicates that 14% of the US
population is above age 60 as compared to about
4.5% of the Native American population. More than
26% of Native American families live below the
federal poverty level. More than 33% of Native
Americans over the age of 25 who live on reservations have not graduated from high school.1
The general health of Native American people
lags significantly behind that of the general US
population based on the latest data highlighted in
Table 1. For certain health statistics, the health
disparities between the Native American population and the general US population are appalling.
The ratio of Native American to general US
population health disparities is particularly striking
for accidents, alcoholism, diabetes, and tuberculosis.
While the current structure of the Indian Health
Service may not be the primary cause of the health
disparities identified in Table 1, it is clear that
this structure (to be discussed later) has not
successfully addressed them. New strategies and
structures aligned with the evolving external

Table 1 Health disparities between the Native

American Indian population and the general US
population for selected mortality indicators
(19941998 data; adjusted rates per 100 000 population).

Homicide
Suicide
Accidents
Tuberculosis
Diabetes
Alcoholism
Pneumonia and
Influenza

General US
population
(1)

Native
American
population
(2)

Ratio
(3)

9.4
11.2
30.5
0.3
13.3
6.7
12.9

15.3
19.3
92.6
1.9
46.4
48.7
22.0

1.6
1.7
3.0
6.3
3.5
7.3
1.7

Source: Trends in Indian health 19981999. Indian Health

Service. Available at: /http://www.ihs.gov/PublicInfo/
Publications/trends98/trends98.aspS.
Ratio 3 2 divided by (1).

297

environmental incentives and constraints will be

required.
The causes of the health disparities summarized
in Table 1 include discrimination, unemployment,
poverty, culture, cultural oppression, lack of
education, and a myriad of other factors. We do
not argue that the current organization of the
Indian Health Services (IHS) is the cause of these
health disparities. Rather, we argue that the
reorganization proposed here will better address
these disparities than will continuation of the
current organization and service delivery model.
First, we will discuss the history and evolution of
the Indian Health Service as well as the limitations
of the current model of health service delivery.
Second, two successful models of health service
delivery to Native American populations are described. Third, our methodology for development
of new models for health service delivery is
described. Fourth, three models of health services
delivery based on tribal size are presented and
described. The paper concludes with recommendations for structuring health services for underserved populations.

Evolution of the Indian Health Service

Historical background
Native American tribes became dependent nations
as a result of being placed on reservations after the
United States Indian wars of the 18th and 19th
centuries. Native American tribes had to depend on
health care provided by the United States as a
provision of various treaties entered into between
Native American tribes and the United States. In
1921, Congress created a health division within the
Bureau of Indian Affairs of the Department of the
Interior. In 1954, Congress transferred the responsibility of Native American health care to the Public
Health Service and created the Indian Health
Service (IHS) within what is now known as the US
Department of Health and Human Services (DHHS).
Today the IHS is the primary source of health care
services for approximately 55% of the estimated 2.5
million Native American people. The IHS is organized into twelve area offices. Table 2 shows these
twelve area offices and their service populations.1
The largest concentration and diversity of Native
Americans is in the state of Arizona consisting of
Phoenix, Navajo, and Tucson with a combined
Native American population of 394 969 in 1998
(see Table 2). This study will focus upon the
structuring and restructuring of public health

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M.T. Allison et al.

service delivery to Native American tribes in

Arizona because this population is larger, more
diverse, and more representative than tribes in any
other state.
In 1975, the US Congress passed P.L. (public law)
93-638, the Indian Self-Determination and Education Assistance Act. Among other provisions, this
act allowed the contracting of IHS and Bureau of
Indian Affairs functions by federally recognized
Native American tribes and tribal organizations.
Since the passage of this act, Native American
tribes and tribal organizations have contracted a
majority of the IHS functions and facilities, with
approximately 44% of the existing IHS budget now
being contracted to tribes and tribal organizations.2 Table 3 shows a breakdown of IHS and
tribally managed health care facilities.
In 1997, a study conducted by the National Indian
Health Board (a national Native American health

Table 2 Indian Health Service area offices and

service populations 19981999.
Area office

Service population

Portland
Billings
Aberdeen
Bemidji
Nashville
Oklahoma City
Phoenix
Navajo
Tucson
California
Albuquerque
Alaska
Total service population

155 876
57 514
100 441
92 597
76 587
313 116
146 777
219 625
28 567
131 005
81 475
107 555
1 511135

Source: Trends in Indian health 19981999. Indian Health

Service. Available at: /http://www.ihs.gov/PublicInfo/
Publications/trends98/trends98.aspS.

Table 3

care advocacy entity) showed that a majority of the

Native American tribes receiving their health care
from tribally contracted entities rated their health
care as now being better than it was under direct
IHS management.3 Moreover, as Table 3 indicates,
74% of the total health care facilities are tribally
operated.
The IHS program is delivered to a service
population of 1.4 million American Indians/Alaska
Natives through 155 service units composed of 594
direct health care delivery facilities, including 49
hospitals, 231 health centers, five school health
centers, and 309 health stations, satellite clinics,
and Alaska village clinics. The range of services
includes traditional inpatient and ambulatory care
and preventive activities. In addition, the IHS is
responsible for environmental health on reservations including health facilities management,
health facilities construction, and sanitation system construction and maintenance.4
Federal funding for Native American health care
is not based on entitlement appropriations, as are
Medicare and Medicaid, but is allocated on a
discretionary basis within the DHHS. This has led
to highly political influences on the IHS budget and
inadequate budget adjustments to keep up with
inflation, as is the case with Medicare and
Medicaid.5 Overall, Congress funds Native American
health care at an average rate of 60% of needs.6
This 60% of needs funding translates into a per
capita expenditure level of US$1776 for IHS
compared with a per capita expenditure level of
US$3660 for a Medicaid enrollee.7
Indian Health Service appropriations per capita
lag behind funding benchmarks for other major
federal health programs. The fiscal year 2003 per
capita expenditure for an IHS beneficiary was
approximately US$2532 (including approximately
US$416 per capita expenditures from third party
collections), compared with US$5645 per capita
personal medical services for US citizens (forecast

Indian health service and tribally operated health facilities, as of 1 October 1998.

Facilities

Hospitals
Health centers
Health stations
Alaska village clinics
Total

49
214
120
160
543

Indian Health Service

Tribal

Actual

Percentage (%)

Actual

Percentage (%)

37
59
44
0
140

76
28
37
0
26

12
155
76
160
403

24
72
63
100
74

Source: Trends in Indian health 19981999. Indian Health Service. Available at: /http://www.ihs.gov/PublicInfo/Publications/
trends98/trends98.aspS.

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Public health delivery models for Native American tribes
for 2003).8 Based on an IHS study using the Federal
Employees Health Benefits (FEHB) plan as a
predictor of Indian health care needs, IHS resources
for medical services (excluding public health and
sanitation resources) are less than 60% of the
comparable FEHB benchmark. Approximately
US$1.8 billion is required, in addition to the
existing IHS appropriation of US$3 billion, to reach
full comparability with mainstream health insurance plans.

Limitations of the current structure

Figure 1 shows the current structure of the IHS.
Health Services are delivered through a system of
interlocking programs composed of the IHS, tribal
programs, and urban programs. Tribal programs
developed through the process of Indian selfdetermination and relatively new urban programs
are both expected to grow significantly in the
future (the latter because of the relocation of
Indian populations from reservations to urban
settings).
IHS headquarters and the IHS area offices have
ties to the tribal governments and the Indianoperated urban projects. Tribal governments have
input into the discussions of IHS operated service
units. The structure is very complex and involves

299

interrelationships between the federal government, tribal governments, and urban Indian
groups.9 Within the IHS, the organization structure
consists of three levels: headquarters, area offices,
and service units composed of hospitals, health
centers, health stations, and clinics.
An ongoing human resource problem is the
recruitment and retention of dedicated, qualified
professionals. The Tribal Self-Governance Demonstration Project allowed selected tribes to take
over complete responsibility for health service
delivery without the need for IHS approval or
oversight. This has created uncertainty about the
future of the IHS and exacerbated recruitment and
retention problems.10
The current Native American health care system
is largely based on a medical model with a majority
of available funding going into direct medical care
(hospital and clinic care) with very few dollars
available for prevention. Due primarily to the lack
of resources and technical knowledge, most Native
American tribes do not have departments of public
health. This situation is a major contributor to the
negative health disparities existing among Indian
people today, on and off reservation. A majority of
Indian people living off reservation have moved
into urban areas in recent years and regularly
travel back and forth to their home reservations to

IHS Headquarters

Indian and Alaskan Tribal

Governments

Indian-Operated Urban Projects

IHS Area Offices

Service Units
Service Units

Hospitals, Health Clinics and

Extended Care Facilities and
Proposed Public Health
Facilities

Hospitals, Health Centers and

Other Clinics

__________

Formal relationships

------------

Important, but less formal relationships

Health Clinics, Outreach, and

Referral Facilities

Figure 1 Elements of the Indian health care system. (Source: Adapted from Tosatto RJ, Reeves T, Duncan WJ, Ginter
PM. Indian health service: creating a climate for change. In: Ginter PM, Swayne LE, Duncan WJ, editors. Strategic
management of health care organizations. Malden, MA, USA: Blackwell Publishers; 2002. p. 679. Permission granted by
Blackwell Publishers, 18 July 2005.)

ARTICLE IN PRESS
300
visit family members to participate in traditional
ceremonial events.
Native American people are very aware of the
lack of public health resources on their reservations
and they recognize the need for prevention services
and programs. Clear evidence of this fact is the
insistence of tribal leaders that Native American
tribes be in primary control of the Native American
special diabetes prevention and treatment funding
appropriated by Congress starting in financial year
1997 (Balance Budget Act of 1997). The clear
expressed desire of the Native American tribal
leadership, throughout the nation, was to do all
they could to prevent their people from getting
diabetes in the first place. Under the management
of tribal governments, a majority of the Native
American special diabetes dollars have been put
into diabetes prevention programs that involve
nutrition and physical activity.
Creation and development of tribal departments
of public health will assist Native American tribes in
their expression of need to establish public health
programs such as diabetes prevention programs.
Additionally, tribal governments have clearly expressed their desires for self-government and selfdetermination through support and contracting of
Indian Health Service and Bureau of Indian Affairs
programs through the provisions of P.L. 93-638, the
Indian Self-Determination and Educational Assistance Act. Through knowledge gained by contracting Indian Health Service public health programs,
tribes are becoming knowledgeable of county and
state public health programs and services, and the
benefits of such entities.
This is the reality of the Gila River Indian
Community, the Hopi Indian Tribe and the Navajo
Nation of Arizona. The Gila River Indian Community
has already established a tribal department of
public health. The Hopi Indian Tribe initiated
conceptual planning for a tribal department of
public health during 2004. The Navajo Nation has
been actively planning for a tribal department of
public health since 2003. In 2005, the Navajo
Nation was awarded a US$40 000 Robert Wood
Johnson Turning Point grant from the National
Indian Health Board to further their planning of
establishing a Navajo Nation department of public
health.
A final problem associated with the current
structure, is the inability of the IHS to bill and
collect adequately for all of the services it
provides. A 1995 report of the Inspector General
of the DHHS estimated that the IHS under-billed by
about US$8.5 million each quarter because of
untrained staff, staff shortages, and lack of
financial controls.11

M.T. Allison et al.

As a result of the above factors, stakeholders in
the IHS have been calling for major changes in the
organization. Such changes will need to respect and
be responsive to different tribal cultures, values,
religions, and traditions. Various economic changes
are also requiring the need for new and innovative
ways to organize and fund programs including local
assessment and definitions of health services
requirements. Yet any new structure will need to
be cost-effective because there are limits to the
resources and services that can be provided to any
given community.

Two models of success

The growth of Indian casino gaming on Native
American reservations helps to provide a few
Native American tribes with financial resources
that were not previously available. The majority of
the tribes do not benefit from casino gambling. This
newly developed source of revenue is being used to
supplement health care programs of those few
Native American tribes.12 As Native American tribes
continue on their path of self-determination and
increasingly secure contracts for IHS programs to
improve the health status of their people, they are
starting to make decisions to create or plan their
own departments of public health.
Two successful models of health services delivery
to Native Americans are the Gila River Indian Tribe
and the Navajo Nation. In Arizona, the Gila River
Indian Tribe has established its own department of
public health.13 Similarly, the Navajo Nation is in
the planning stages of establishing its own department of public health.14 Creation of departments of
public health by Native American tribes signifies
that the tribes are in control of their own health
planning and have professional public health
management.
The Gila River Department of Public Health is
comprised of 11 programs and employs approximately 160 people. The 11 programs comprising
their health department are: Administration, Disease Surveillance, the Environmental Health Program, the Food Distribution Program, Maternal/
Child Nutrition (Woman, Infant, and Children),
Medical Transportation, Public Health Education,
Public Health Nursing, Public Health Nutrition, the
Tobacco Tax & Health Care Fund, and the Wellness
Center. The Department has been very successful in
incorporating western public health concepts into
the governmental structure of the Gila River Indian
Community. The Department has had much success
in building partnership and collaboration arrangements with their local county, the state health

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department and different federal agencies such as
the Indian Health Service.13
In 1977, the Navajo Tribal Council established the
Navajo Division of Health Improvement Services
and in 1995 renamed it the Navajo Division of
Health. The Division employs over 1100 health
professional, paraprofessional, and technical personnel stationed throughout the Navajo Nation and
is comprised of fifteen programs. The fifteen
programs comprising the Division are: Administration, Health Facility Steering Committees, the
Department of Behavioral Health, the Food Distribution Program, the Women, Infants, and Children Program, Environmental Health, the New
Dawn Program, the Office of Navajo Uranium
Workers, Kayenta Public Health Nursing, the Navajo
Area Agency on Aging, the Native American
Research Center for Health Project, the Community
Health Representative/AIDS Program, the Breast
and Cervical Cancer Project, the Special Diabetes
Project, and the Health Education Program. The
Division has been in existence for 28 years, a
testament to its success.14 The two successful
models above are much further ahead than most
tribes at this time (2006) in providing public health
to tribal members. However, they do provide some
parameters upon which other tribes might build
their public health services for the future.
This paper presents three public health organizational models based on the two examples above
that could be used by Native American tribes in
their public health planning activities. Many tribes
are located in frontier areas where there are few, if
any, community health resources, and cultural
barriers posed by non-tribal health care institutions
in rural areas may impede health access. For these
reasons, the authors believe that most tribes will
be better served when they own their own health
care facilities. Of course, this will not preclude
selective contracting for particular community
health care services that a given tribe may be
unable to provide.

Methods
The State of Arizona was selected for our study due
to the large number and diversity of Native
American tribes in the state. Staff interviews were
conducted with 91 individuals from the Arizona
Department of Health Services (ADHS) in 2003
including middle and upper management program
directors, deputy directors, key support staff and
division directors. Twenty-nine staff members were
interviewed from the Division of Behavioral Health

301

Services along with 13 staff members from the

Division of Assurance and Licensure Services, 26
from the Division of Public Health Services, five
from the Division of Information Technology Services, four from the Division of Business and
Financial Services, and 14 from the Director and
Deputy Directors office.
Each interview was conducted in-person without
the use of a questionnaire, lasted 6090 min, and
consisted of three parts. Part one was an introduction and project overview, part two consisted of an
explanation of job roles and responsibilities, and
part three consisted of a question and answer
period. The primary purpose of the interviews was
to obtain a working knowledge of the purpose and
operation of a state department of public health
(ADHS) and to determine the applicability of
utilizing some versions of the ADHS mode of
operation for development of Native American
Indian (NAI) tribal departments of public health.
The Arizona Department of Health Services is
organized into five major divisions. These five
divisions are the Division of Business and Financial
Services, the Division of Information and Technology Services, the Division of Public Health Services,
the Division of Licensing Services, and the Division
of Behavioral Health Services (which includes
management of the state behavioral health hospital). The Division of Business and Financial Services
handles all the accounting and finance functions.
The Division of Information and Technology provides all computer hardware and software needs.
The Division of Public Health Services houses all
public health service programs. The Division of
Licensing Services handles most of the licensure
and regulation of health and childcare facilities
operating in the state. The Division of Behavioral
Health Services primarily provides behavioral
health services to the Medicaid and Medicare
population of the state. Interviewees were asked
to comment on the feasibility of various models for
public health care delivery to the Native American
population.
The health delivery models were also developed
after interviewing Arizona government officials,
and tribal health directors across the state. The
models are structured to reflect the priorities of
current tribal health delivery and build on structures that are already in place. In general, the
models we present are appropriate for state
government and also fit the political environment
(in particular, the funds available to the tribal
government).
The ADHS provides a majority of its public health
services through contracts with the states 15
counties and other contractors who provide direct

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services to the population. The ADHS Behavioral
Health Services are provided through contracts
with managed care companies. It should be noted
that resources to develop public health departments in most tribes are limited due to limited
financial resources in Native American communities
and consistent under-funding of the IHS. The
recommended organizational models were developed based upon a systematic assessment prior to
the actual design as suggested by Leatt et al.15
Such an assessment takes into account the external
environment as well as the organizations mission,
organization capabilities, and human resource
capabilities.

Results
The above interviews revealed that the ADHS
operated on certain management principles including: (a) management contracts and subcontracts
with various federal, state, and local agencies; (b)
joint efforts with federal agencies for licensure and
certification; (c) delivery of health promotion and
disease prevention programs through county health
departments and tribal health departments; and
(d) information technology to assure that expenditures are in compliance with all state/federal rules
and regulations.
Based upon the knowledge gained from the ADHS
personnel interviews, as well as the personal health
care knowledge of the first author (M.T.A.), three
organizational models are proposed based on tribal
population size (small, medium, and large). These
also reflect the reality that North American tribes
differ from one another in terms of population,
geographic location, culture, and reservation land
acreage. Small Native American tribes are defined
as tribes having a membership of fewer than 5000
people. Medium tribes are defined as tribes having
a membership of between 5001 and 15 000 people.
Large tribes are defined as tribes having a membership greater than 15 000 people. The rationale for
dividing our models by tribal population is the
ability or inability of different sized tribes to
support the provision of particular services.
The small and medium models are based on an
organizational structure comprising the following
four functional areas: (a) a Directors Office; (b) a
Division of Epidemiology and Public Health Statistics; (c) a Division of Family and Community Health
Services; and (d) a Division of Behavioral Health
Services. The Directors Office would provide overall department executive leadership and administrative support. The Epidemiology and Public

M.T. Allison et al.

Health Statistics Division would provide epidemiology data collection, public reporting, and disease
outbreak services. The Family and Community
Health Services Division would provide public
health promotion and disease prevention services.
The Behavioral Health Services Division would
provide behavioral and mental health services.
The large model contains these four functional
areas plus three additional areas: a Division of
Business and Finance, a Division of Information
Technology, and a Division of Licensure Services.
The numbers of individual staff members and
programs increase progressively from the small
model to the large model.
These models are designed with the premise that
tribal governments are direct care providers,
rather than indirect care providers like the ADHS.
Our models build on existing services provided
through the IHS. These include preventative health
(e.g., free pre- and postnatal care, health education), medical services (e.g., inpatient hospitalization, outpatient services, contract services),
behavioral health (e.g., alcohol and substance
abuse services), IHS initiatives (e.g., maternal and
child health, AIDS initiatives), and environmental
health (e.g., water treatment).16 Figure 1 represents the structure of the IHS. Our models fit into
this representation, providing more details on the
service units represented by the box on the lower
left of Figure 1.

Small tribe model

Figure 2 shows the organizational chart for the
small tribe model. The department director reports
directly to the tribal Presidents office (Chief
Executive Officer of the tribe). The department
director need not have a medical background;
however, he/she should have public health management experience. At least three full-time staff
members and a contracted or part-time medical
director will work in the directors office. The fulltime staff should include the director, a planning
and evaluation officer, and a finance and budget
officer.
The Division of Epidemiology and Public Health
Statistics has the primary function of managing all
data collection, analysis, reporting, data sharing,
and disease outbreak control. Additionally, this
division is responsible for food and water safety in
so far as a health department can control it. These
functions should be divided into three program
components consisting of: (a) vital records management; (b) infectious and communicable disease
control and monitoring; and (c) environmental

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303

Tribal Council
President
Director
Medical Director

Planning and
Evaluation

Finance and Budget

Division of Epidemiology and

Public Health Statistics

Division of Family and Community

Health Services

-Vital records
-Infectious and Communicable
Disease Control

-Women, Infants and Children

-Community Health Rep.
-Nutrition and Chronic Disease

Division of Behavioral
Health Services

-Substance Abuse

-Environmental Health
Assumptions: Central government will provide overall accounting and finance, auditing, legal, and personnel management.

Figure 2

Department of Public Healthsmall tribe model.

health. A full-time division director and two or

three full or part-time employees staff this
division.
The Division of Family and Community Health
Services has the primary function of managing all
health promotion and disease prevention programs
established by the tribe, such as the Women, Infant
and Children (WIC) program, the Community Health
Representative (CHR) program, and other nutrition
and chronic disease prevention and promotion
programs. This division has a full-time division
director and appropriate staff. It has the largest
number of department staff because of its role in
direct care.
The Division of Behavioral Health Services has the
primary function of managing all behavioral health
and substance abuse programs established by the
tribe, such as outpatient care, residential treatment coordination, aftercare, and traditional medicine. This division also has a full-time division
director and appropriate staff. It is also responsible
for coordinating activities with the state mental
health hospital.
The tribal central government provides overall
finance, auditing, legal, and personnel management support functions, a major challenge for all
tribes given their location in rural and frontier
areas. Some sort of federal government incentive
system might be necessary to help tribes attract
the needed professional and managerial staff.

Medium tribe model

Most tribes are not large enough to support the
medium tribe model described below or the large
tribal model described in the next section. In some
areas, it might be possible to support inter-tribal
health departments; this is discussed later in the
paper.
Fig. 3 shows the organizational chart for the
medium tribe model. The department directors
office in this model is similar to that of the small
tribe model, albeit with the following important
changes. Two new staff positions are added: a
communication and legislative aid officer, and an
information technology officer. Second, the position of medical director is changed from part-time,
or contracted, to full-time. The communication
and legislative aid officer position is responsible for
all public relations communications and providing
aid to the department director on legislative
communications. The information technology officer position is responsible for providing technological support (e.g., computer software and
hardware) to the department staff.
The Division of Epidemiology and Public Health
Statistics is similar to the small tribe model with
the addition of an emergency preparedness program component to monitor and coordinate all
public health emergency preparedness programs
and projects.

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M.T. Allison et al.

Tribal Council
President
Director
Medical Director
Finance and
Budget

Planning and
Evaluation

Communication and
Legislative Aid

Information Technology

Division of Epidemiology and

Public Health Statistics
-Vital records
-Infectious and Communicable
Disease Control
-Environmental Health
-Emergency Preparedness

Division of Family and Community

Health Services
-Women, Infants and Children
-Community Health Representatives
-Nutrition and Chronic Disease
-Children with special health
care needs
-HIV/AIDS

Division of Behavioral
Health Services
-Substance Abuse
-Mental Health

Assumptions: Central government will provide overall accounting and finance, auditing, legal, and personnel management.

Figure 3

Department of Public Healthmedium tribe model.

The Division of Family and Community Health

Services in this model is similar to that division in
the small tribe model, with the addition of two new
program componentschildren with special health
care needs and HIV/AIDS.
The Division of Behavioral Health Services is
similar to that in the small tribe model with the
addition of mental health as a separate program
component. The mental health program is responsible for all treatment programs for the mentally ill
and seriously mentally ill. The tribal central
government provides overall finance, auditing,
legal, and personnel management support functions.

Large tribe model

The organizational chart for the large tribe model is
shown in Fig. 4. Due to increased organizational
responsibilities, this model is the most complex of
the three organizational models. The directors
office is similar to that in the medium tribe model
with the following major changes and additions. A
deputy director position is added, along with a fulltime human resources manager and auditing
manager. The communication and legislative aid

officer position is divided into two new positions, a

public information officer and a legislative liaison
officer. The finance and budget officer and the
information technology officer positions are expanded into two new divisions, a division of
business and budget, and a division of information
technology.
The deputy director is responsible for assisting
the director in managing the department. The
human resources manager is responsible for managing all personnel functions. The auditing manager
is responsible for coordinating all auditing activities
and special investigations. The public information
officer is responsible for all media and public
communications. The legislative aid officer is
responsible for assisting the department director
in communications with the tribal council and its
legislative committees.
The addition and creation of new departmentwide programs and projects require additional
administrative accounting and finance support
staff, resulting in an expansion of the finance and
budget officer position into a new Division of
Business and Budget. Also, as new programs and
staff are created and hired, there are increased
internal demands and needs for information technology support, resulting in an expansion of the

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Public health delivery models for Native American tribes

305

Tribal Council

President
Public Information
Officer

Medical Director
Director
Planning and
Evaluation

Legislative Liaison
Deputy Director
Auditing Manager

Division of
Business and
Budget

Division of
Information
Technology

Division of
Epidemiology and
Public Health Statistics

Human Resource Manager

Division of Family and

Community
Health Services

Division of
Behavioral Health
Services

-Substance Abuse

-Budget Office

-Security

-Vital records

-Women, Infants and Children

-Accounting

-Technical Support

-Finance

-Applications

-Infectious and
Communicable
Disease Control

-Community Health Rep.

-Mental Health
-Nutrition and Chronic Disease -Consumer Rights
-Children with special health
care needs

-Environmental Health
-Emergency Preparedness
-Immunization

-HIV/AIDS
-Oral Health

-Tribal Epidemiologist

-Emergency Medical Services

Division of
Licensure
Services

-Medical Facilities
-Child Care
-Long-Term Care

Assumptions: Central government will provide legal services.

Figure 4 Department of Public Healthlarge tribe model.

information technology officer position into a

Division of Information Technology.
The Division of Epidemiology and Public Health
Statistics is similar to that in the medium tribe
model, with the additions of an immunization
program and the establishment of a tribal epidemiologist position. The immunization program is
responsible for monitoring and coordinating all
immunization programs and projects initiated on
the reservation. The tribal epidemiologist is responsible for monitoring and coordinating all
epidemiological activities, especially disease outbreak control.
The Division of Family and Community Health
Services is similar to that in the medium tribe
model with the addition of two new programsoral
health care and emergency medical services,
responsible for coordinating ambulance care and
first responders services.

The Division of Behavioral Health Services is

similar to that in the medium tribe model with the
addition of a consumer rights office, responsible for
the protection of patients rights.
A new Division of Licensure Services will be
created. This new division will be responsible for
monitoring and enforcing public health licensure
laws and regulations enacted by the tribal council
in order to monitor and regulate health care
providers and facilities operating on the reservation (e.g., medical facilities, nursing homes, and
childcare centers). The central tribal government
will provide legal support services.

Sub-offices
Some larger tribes, such as the Navajo Nation and
Tohono Oodham Nation of Arizona, have sub-offices

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306

M.T. Allison et al.

serving a sub-region of their respective reservation

populations. In such cases, it might be feasible and
appropriate for the tribal health department to
establish local sub-offices operating under the
jurisdiction of the main tribal health department.
Figure 5 provides an organizational chart of this
sub-office model.
Each sub-office would have directors who report
directly to the tribal health department director or
indirectly through an overall supervisor. The staff of
these sub-offices provide direct services to the subregion reservation population and receive support
and funding from the main tribal health department.
Larger tribes with this structure may some day
explore the possibility of establishing these suboffices as political subdivisions of their respective
tribal government, thus making them similar to
county governments. In such case, the internal tribal
relationship between the sub-offices and the central
tribal health department might evolve into one
similar to a state/county relationship such as at
ADHS, wherein the sub-offices provide direct population services and the central tribal health department would provide pass-through funding, training
and technical assistance to the sub-offices.

Discussion
American Indian tribes represent an underserved
minority for which the delivery of health services
has been inadequate in terms of funding, human
resources, and health outcomes. As a result of the
changing internal and external environments of the
IHS as well as the subsequent pressure from its
stakeholders for organizational change, the IHS has
been seeking new models for health care delivery.
These models need to reflect the differing circumstances and cultures of different tribes in different

locations and to provide preventive as well as

curative services.
This paper presents three tribal department of
public health organizational models responsive to
the above concerns and is intended to provide tribal
leaders, tribal health directors, and other interested
individuals and entities with information that could
assist in the planning and establishment of tribal
departments of public health. It is understood that
each Native American tribe is unique, requiring a
unique approach to health care infrastructure. To
address the limitations of human and financial
resources, small and medium sized tribes may
consider establishing tribal departments of public
health on an inter-tribal basis with other tribes
located in their geographic areas. Such entities
would serve the public health needs of several tribes
located in the same geographic areas. Some
counties in the USA have such relationships.17
Planning and establishing of tribal departments
of public health will increase public health knowledge among tribal leaders, health care staff, and
the general reservation population. It signifies that
Native American tribes are serious in their efforts
to control and monitor all aspects of the planning
and delivery of public health services to their tribal
members and other people residing on their
reservation lands. State departments of public
health staff might provide requested training and
technical assistance.
The organization suggested in this paper may be
too radical or too threatening for the Indian Health
Service or some of the tribes. An alternative
strategy may be an incremental approach in which
the models proposed here are viewed as long-term
goals, but the specific changes needed to achieve
these goals are implemented step-by-step over a
period of years. For example many of the public

Tribal Health Director

Agency/District Director

Administrative Support

Epidemiology and Disease

Control Program
Coordinator

Planning and Evaluation

Family and Community

Health Services Coordinator

Behavioral health
Services Coordinator

Figure 5 Department of Public Healthagency/district sub-office model.

ARTICLE IN PRESS
Public health delivery models for Native American tribes
health services specified to be provided by the
tribes themselves in Figs. 24, could be contracted
out to other community providers until a sufficient
number of tribe members have been trained in the
required health professions to provide the public
health services noted in the three proposed
models. Some tribes (i.e., those benefiting from
casino gambling revenue) might be able to implement the new models immediately while other
tribes may do so only over a number of years
based upon their available funding and trained
personnel. The rural/frontier location of the
majority of tribes also suggests that recruiting
quality staff will undoubtedly be challenging.
One promising approach might be for the IHS
and local tribes to partner with local junior colleges
and technical schools to train tribal members in
various health professions including nursing. The
feasibility and cost of developing public health
departments and possible sources of funding must
be addressed in a follow-up paper as they lie
outside the scope of this one. These should be
developed initially as demonstration projects.
Future research should then evaluate the costeffectiveness and clinical effectiveness of these
demonstrated projects prior to their implementation on a broad scale.
Lessons learned from this experience, that may
be applicable to developing and implementing
health services for all underserved populations,
include the following:







service delivery should focus on both preventative and curative services;

services should be developed with input from the
underserved population;
members of underserved populations should be
trained to provide service to their communities;
one model of health service delivery will not be
appropriate for all underserved populations; and
different models will be required to respond to
differing cultures, populations, and geographic
locations.

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