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Part C: THE CURRENT IHDT PLAN Introduction In its 40 year history, the IHS has only made incremental changes in its structure despite sweeping external and internal changes in society. External changes identified by the IHDT include public sentiment that seeks to downsize government. Although IHS staff was previously exempt from this pressure, the current budget calls for the reduction of 1000 full-time equivalents (FTE’s) in the next five years. Increased medical costs, advanced technology and stricter medical practice standards are also exerting external pressures. Internally, the Indian population health needs have also shifted. Initial critical needs 40 years ago were immunization, sanitation and infant mortality. While tremendous progress has been made in improving outcomes in these areas, emerging issues today include access to primary care, high rates of alcoholism and injury, and the need for mental health services. Since the enabling legislation of the 1970's, around a third of the IHS resources are now contracted through tribal organizations. This represents a major shift in participation and delivery, yet this 1990's system remains molded in a 1950's organizational structure.

Michael Lincoln, Deputy Director of IHS cautiously reported to the Senate that "the challenge before the Tribes, Indian health programs, the IHS and the Congress is to retain the Indian health programs’ applied expertise in core public health functions that are critical to elevating the health status of American Indians....and reducing the disparity in the health status of AI/ANS compared to the general population. We, who are involved in Indian health care, must deal with a changing external environment with new demands, new needs, and new priorities" (Statement before the Senate Committee on Indian Affairs, 1995, on-line).

The Indian Health Services has just completed a revised organization structure proposal through the IHDT. In a span of just two years, form October 1994 to February 1997, a plan for this restructuring was created, adopted, and already in the first phase of implementation. Under Michael Trujillo’s lead, this bipartisan plan recommends a decentralizing relationship that emphasizes local tribal control.

Section 1: Setting the Stage and Lessons Learned The first formal meeting of the IHDT was in October of 1994. While the IHS laid out its plans to restructure under the National Performance Review guidelines (NPR, reinventing government), tribal attendees had these comments to make. It was made clear that if the current structure was going to solicit input from the Tribes, then that input was going to be strong.

Tribes do not have agendas for reductions. The Administration’s agenda for reductions is not the agenda of Tribal leaders.

The treaties made with Tribes do not include a responsibility for paying for deficits.

Resources for Indian health care should be adequate to match the oaths this government made in exchange for millions of acres of land.

Credibility for the design will earned if Tribes identify what the Agency is to be.

Participation of elders in the change process is important because of their role in maintaining the family unit.

These comments did come without a recent and powerful precedent. In 1990, then Secretary of Interior Lujan created a Task Force to study reorganization of the BIA. Its charge was to come up with recommendations just like the IHDT. At that time, this Task Force was unique in that it sought full tribal participation in the planning process. Like the current IHDT, their was strong Tribal representation with 36 of 43 members coming from non-BIA employees. Under the auspices of the National Performance Review, another plan was created. While both plans agreed that decentralization of government involvement and the redistribution of authority to local levels was important, the NPR "ignored the work of the Task Force and in fact, failed to involve the tribal leadership, even on a consultative basis" (Shields, 1995, pg.2).

Caleb Shields is Tribal Chairman of the Assiniboine and Sioux Tribes of the Fort Peck Reservation in Montana. He was a member not only of the BIA Task Force but is also a member of the IHDT. He very pointedly questioned the motivation of the NPR recommendations and wondered how their plan would benefit Indians.

Where the Task Force sought to bring about reorganization of the BIA to improve its performance while meeting the needs of the tribes and Indian people, NPR is forcing the reorganization of BIA (and IHS too) to meet the budgetary commitments of the Administration without regard to its impact on BIA performance or the needs of the tribes and Indian people (Shields, 1995 p.3).

If the federal government was going to solicit input from the Tribes to "reinvent" government, it would not be just a symbolic participation that was going to occur. The agenda for restructuring was not going to be one where the outcome did not fulfill the social function of the agency that was designed to deliver it and that less than a full partnership in this process was unacceptable.

This message was reinforced when the BIA tried to present its reorganization plan to tribal leaders in Billings, Montana three months later. Tribal leaders walked out of the meeting stating that the request for their input was "false involvement…As far as the consultation process, I feel it’s a done deal. Why did you even ask us to come here?" (McCraken, 1995).

In a paper written specifically for the first formal meeting of the IHDT, Eric Bothwell presents his findings from literature and offers his opinion as to why and how the team might proceed.

We are simultaneously faced with political/fiscal pressure to downsizing our administrative infrastructure, turning control and resources over to tribes wishing to exercise their right of self-determination, and reinventing ourselves through the directives of the Reinventing government/National Performance Review. Any one of these forces alone would warrant the need to consider some type of reorganization, but collectively they create an absolute mandate for significant change, and very soon (Bothwell, 1995).

He cites three basic assumptions for why a change is necessary. First, that two converging streams are present making action timely; new values and economic necessity. Second, he makes the assumption that a proactive stance must be taken to manage the change, for change is inevitable and will proceed with or without the input of an IHDT. Third, it is assumed that the IHS will remain a provider for tribes not exercising self-determination options, therefore IHS needs to retain some infrastructure. Underlying all of this is the belief that IHS appropriations will not be increasing in the future, but will do will to just maintain its current level.

An admonition from Bothwell to the IHDT members at the first meeting cuts right to the core. He asks if the recommendations that they will be making will merely be cosmetic changes, or whether they will rather be the needed bone surgery. "The notion that organizational beauty is only skin deep but organizational ugliness (ineffectiveness) goes clear to the bone, appears true. A variety of reasons have been identified for this pattern of organizations only achieving cosmetic surgery, or downsizing to nothing more than a smaller but still dysfunctional organization." He asks that "we [be] better than that!" (Bothwell, 1995).