Tribal health departments (THDs) are increasingly involved in public health activities in rapid response to the changing health needs of American Indian and Alaska Native communities. In the era of health care reform and accountability, tribes recognize the importance of strengthening public health infrastructure as a means for generating resources, and increasing efficiency and effectiveness of programs and services. High rates of chronic diseases, such as diabetes, heart disease, and cancer, are among the leading causes of death and disability in many tribal communities1 and are largely preventable. A stronger tribal public health infrastructure may lead to improvements in health outcomes and a greater capacity to respond to important public health issues.
Recent attention to a national program for public health department accreditation is an opportunity to advance quality and performance within THDs. The accreditation process may provide a means for THDs to identify performance improvement opportunities, bolster management practices, develop leadership, and strengthen important relationships in the community. In 2009, the National Indian Health Board (NIHB), through funding from the Robert Wood Johnson Foundation, assessed the feasibility of promoting voluntary public health accreditation and developing public health standards for THDs.2 Four key recommendations emerged: (1) Develop a tribal set of standards and measures; (2) Educate and inform tribal leaders and THDs about public health accreditation and its benefits; (3) Provide technical assistance, accreditation readiness tools, and training specific to the uniqueness of tribes and THDs needed to prepare them for public health accreditation; and (4) Provide opportunities to strengthen tribal/state relations as it relates to accreditation.
The Public Health Accreditation Board (PHAB), a nonprofit organization serving as the public health department accrediting body, recognized the unique and critical role that tribal governments have in developing the accreditation program. In response, PHAB engaged in a consultative process by participating on the Tribal Public Health Accreditation Advisory Board, convened by NIHB, hosting a Tribal Think Tank, and increasing involvement of tribes and tribal public health professionals in the beta test of the accreditation process. In 2010, PHAB convened a Tribal Standards Workgroup to develop tribal standards that were later vetted through a national call for tribal input. The final outcome was a combined set of standards and measures for tribal, state, and local health departments found in the PHAB Standards and Measures, Version 1.0, approved May 2011.3
Tribal Readiness for Accreditation
Little is known about tribal readiness for public health accreditation. In 2010, NIHB released a national tribal public health profile based on results of a tribal public health capacity assessment. The assessment revealed that THDs provide an array of health services, with diabetes screening, chronic disease prevention, substance abuse services, blood pressure screening, behavioral health, and immunizations being among the most common. Thirty-six percent of assessment respondents conducted a community health assessment, a prerequisite of accreditation, in the past 3 years.4 While this information is helpful, it only scratches the surface to understanding the capacity of THDs to pursue public health accreditation.
Many THDs provide clinical services and are familiar with quality assurance/improvement and accreditation of their clinics, hospitals, and ambulatory care facilities through accrediting bodies, such as the Accreditation Association for Ambulatory Health Care or Joint Commission on Accreditation of Healthcare Organizations. Given this experience, there are reasons to suggest that THDs have the capacity to assess public health performance and explore improvement opportunities to address a set of accreditation standards. However, greater investments are needed to build tribal public health infrastructure and capacity.
National public health initiatives focusing on public health systems and performance improvement have increased opportunities for tribes to plan and prepare for accreditation. The Centers for Disease Control and Prevention's National Public Health Improvement Initiative (NPHII), through the Prevention and Public Health Fund of the Affordable Care Act, is a 5-year initiative supporting public health accreditation readiness activities, performance and improvement management practices and systems, and implementation and sharing of practice-based evidence.5 NPHII grantees include 5 tribes and 4 regional, tribally governed organizations.
National organizations, such as the National Association of County & City Health Officials, the Association of State and Territorial Health Officials, the American Public Health Association, and the National Network of Public Health Institutes, have also regranted funds to tribes and tribally governed organizations to participate in accreditation and performance improvement activities through the funding from both the Centers for Disease Control and Prevention and Robert Wood Johnson Foundation. The Institute for Wisconsin's Health, the Northwest Portland Area Indian Health Board, the Inter Tribal Council of Arizona, and the California Rural Indian Health Board Tribal Epidemiology Center partnered with Red Star Innovations, a national tribal public health consulting organization, to deliver a 3-day Tribal Public Health Accreditation Workshop Series in their region. The workshop series covers (1) accreditation 101: process, benefits, and opportunities; (2) accreditation readiness and self-assessment; and (3) planning and preparing the 3 prerequisites. To-date, the workshop series has been provided to nearly 36 tribes in 6 states; and even more have participated in webinars, workshops, and trainings to learn more about accreditation. As a result, tribes in these regions, and others, have made a commitment to pursue public health accreditation.
Effective public health systems are important to protecting the well-being of tribal communities. Public health accreditation is an opportunity to strengthen tribal self-determination by providing a framework for tribes to improve public health infrastructure and build capacity. Many tribes recognize the value of strengthening public health infrastructure to generate resources and increase the efficiency and effectiveness of programs and services. However, greater financial investment, outreach and education, and stronger partnerships with local and state health departments, among other resources and support, will be needed to advance participation in accreditation activities among tribes.
A significant challenge to strengthening tribal infrastructure is financial. Indian health care is significantly underresourced.6 The Indian Health Service (IHS), a federal agency within the Department of Health and Human Services, is responsible for upholding a trust responsibility to provide health care to members of federally recognized tribes. In 2005, IHS per capita expenditures were about half of the national health per capita expenditures and less than half of Medicare.7 Although many tribes now manage their health care through contracts and compacts with IHS, many public health services are not reimbursed. Tribes rely on grants, revenue generated through economic enterprise, and other sources to supplement existing services. Financial incentives such as cost reimbursement for public health services could potentially reduce the monetary barrier and increase the return on investment for some tribes.
Many tribes deliver important public health services in partnership with local and state health departments. The extent to which tribes partner with these, and other public health entities, varies by tribe, state, and type of service. Challenges often arise when the federal government transfers responsibility and funding for public health functions to states, as is often done through block grants. Tribes are not routinely consulted or engaged in planning at the state or local level. For example, in response to the 2001 terrorist attacks, federal money was quickly appropriated to improve preparedness and public health emergency response, the amount that reached tribes was largely determined by the Tribal-State relationship and whether states included tribes as part of their public health network. Public health accreditation may provide opportunities to achieve shared goals for public health improvement by promoting communication, partnership, and collaboration among tribal, local, and state health departments.
Organizations and governmental agencies at the local, state, and national levels will need to expand their outreach and education efforts to include tribes in the system benefits of achieving public health accreditation. Formal partnerships, the development of tribally specific accreditation readiness tools and other supports will further support THD participation in accreditation. Certainly, the Tribal Epidemiology Centers, established in each IHS Administrative Service Area in 1997, will be a resource that can be utilized by many tribes for surveillance, community health profiles, and other public health functions.
A stronger tribal public health infrastructure may lead to improvements in health outcomes and greater capacity to respond to important public health issues. Resources such as incentive funding, targeted outreach and education efforts from regional and national public health organizations, and creative and strategic partnerships are needed to support tribal participation in accreditation. Interest in public health accreditation among THDs may not grow until the investment in their participation reaches a level to tip the cost-benefit threshold that each public health department considers when deciding to apply for accreditation.
1. Indian Health Service. Trends in Indian Health 2002-2003 Edition. Rockville, MD: US Department of Health and Human Services, Indian Health Service, Office of Public Health Support, Division of Program Statistics.
3. Public Health Accreditation Board. Public Health Accreditation Board Standards and Measures, Version 1.0. Alexandria, VA: Public Health Accreditation Board; 2011.
4. Knudson A, Hernandez A. A profile of tribal health departments. NORC Walsh Center for Rural Health Analysis. Practice Brief, June 2012, W Series No. 18.
5. Centers for Disease Control and Prevention, Office for State, Tribal Local and Territorial Support. National Public Health Improvement Initiative. Available at: http://www.cdc.gov/stltpublichealth/nphii
. Accessed June 10, 2013.
6. Lillie-Blanton M, Roubideaux Y. Understanding and addressing the health care needs of American Indians and Alaska Natives. Am J Public Health 2005;95(5):759–761.
7. Department of Health and Human Services. 2005 IHS Expenditures Per Capita Compared to Other Federal Health Expenditure Benchmarks. Washington, DC: US Department of Health and Human Services; 2006.