Gaining Ground in California

A CRIHB Project to increase public health accreditation readiness in California’s tribal jurisdictions.

Gaining Ground is a two-year initiative managed by the National Network of Public Health Institutes.  California was one of 7 states selected for the funding from the Robert Wood Johnson Foundation with the goal to develop sustainable statewide systems to catalyze public health accreditation and support performance improvement in tribal and small, rural local health departments.  California, with CRIHB’s assistance aims to increase public health accreditation readiness in California’s tribal jurisdiction and to increase cross-jurisdictional collaboration between CDPH, local health departments, and California tribal jurisdictions to maximize efforts in performance improvement and accreditation readiness. The Gaining Ground Project is managed by CRIHB’s department of Research & Public Health.

So far, a Tribal Public Health Accreditation Readiness assessment has been disseminated to all of our tribes and tribal heath programs.  This readiness assessment was adapted from the one used to determine where local health departments in California are at for comparison data.  Some of our next steps include planning “Meet and Greets” between tribes and tribal health programs and the local health departments that are in the same counties, holding community health improvement planning trainings with the tribes, sitting on the conference planning committee for which we plan to have one in Northern California and one in Southern California, develop a California tribal specific tool-kit to inform and guide tribal health programs interested in pursuing public health accreditation, and finally the goal is for a minimum of one tribal health program will complete a tribally focused community health assessment in preparation for public health accreditation by the end of the initiative in April, 2016.

 Vision for Voluntary Public Health Accreditation in Indian Country

As sovereign nations, tribes are responsible for the overall health and well-being of their members along with the land and environment of their tribe. Tribes are becoming increasingly involved in more public health activities and regulation and deliver public health services through various funding sources, grants and contracts, alone or in partnership with other tribes and local, county and state health departments. As a result, the definition of public health in Indian Country is a complex set of services and activities that involve a diverse set of partners and stakeholders that varies by tribe and region. Tribes have a vested interest in providing valuable public health services to the communities they serve, and accreditation may lead to overall improvement in the quality of services they deliver.

VISION: Tribal public health accreditation will contribute to vibrant, healthy tribal communities through collaboration by all agencies responsible for public health service delivery and the development of accessible, culturally-relevant, competent, accountable and sustainable public health programs and services that promote the health and sovereignty of American Indian and Alaska Native tribes.

Benefits of Voluntary Public Health Accreditation:

Public Health Accreditation will result in better quality of and access to culturally appropriate public health services for in tribal communities because it achieves the following:

  • Defines and strengthens the roles and responsibilities of tribal governments in regulating public health in their community.
  • Raises the visibility of public health benefits in your tribal community.
  • Clarifies how public health includes prevention and wellness to reduce health disparities.
  • Assesses strengths and areas for improvement in public health services
  • Encourages stronger partnerships with entities that do public health for our communities, including states, counties, local, tribes, federal, private, non-profits, etc.
  • Leads to more resources for public health, such as and grant opportunities and long-term cost savings.
  • Provides opportunities for tribal communities to plan for wellness in their communities.

Definition of Public Health in Indian Country

Public health services are delivered by a diverse and varied set of stakeholders and partners in tribal communities. Traditionally, healthcare has been delivered to American Indians and Alaska Natives through the Indian Health Service, an agency within the Department of Health and Human Services. The Indian Health Service (IHS) was established in 1955 as a comprehensive, primary care health system of hospitals and clinics located on or near Indian reservations. The Indian Health Service provides direct patient care, limited referral services and some public health services.

Since the 1970s, tribes have increasingly opted to enter into contracts or compacts with the federal government to administer the health programs in their community that were previously managed by the Indian Health Service. Public Law 93-638, the Indian Self-Determination and Educational Assistance Act of 1975, provided the authority for this transition to tribal management of federal health programs. Each tribe decides which programs it wants to compacts, which may include some or all of the health programs managed by Indian Health Service and may include public health services.

As sovereign nations, tribes are responsible for the overall health and well-being of their members along with the land and environment of their tribe. As a result, tribes may develop laws or tribal codes to regulate public health services and functions in their communities. Tribes with more resources or those tribes with larger populations tend to be involved in more public health activities, especially if they have contracted or compacted all of the health programs previously managed by Indian Health Service in their communities. In addition tribes may deliver public health services through federal, state and other non-profit grants and contracts. Involvement of tribes in healthcare delivery in their communities often results in more programs or a greater emphasis on public health activities such as prevention and wellness programs. Tribes may also provide public health services in their communities in partnership with local, county and state health departments. The extent of tribal partnerships and relationships with these other public health entities varies by tribe, state, and type of service. A lack of communication or willingness of these partners to work with tribes is a common concern.

Presidential Executive Order 13175 Consultation and Coordination with Indian Tribal Governments requires regular and meaningful consultation and collaboration with 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 through block grants, tribal consultation at the state level is not routinely accomplished. administer and negotiates with the Indian Health Service to enter into these contracts and  As a result, the definition of public health in Indian Country is a complex set of services and activities that involve a diverse set of partners and stakeholders that varies by tribe and region. There is no one model or definition of public health in Indian Country. However, it is clear that all stakeholders want to provide quality public health services to the populations they serve, and accreditation may provide an opportunity for improvement in partnerships and collaboration. The diversity of public health services and stakeholders certainly presents a challenge to the development of an accreditation process that would apply to all tribal settings.