What Tribal Council Needs to Understand
Tribal Council has a different responsibility from the Health Director. Council governs the Tribal health program; the Health Director manages it. Good governance depends on understanding what the health program can do, what it cannot do, and what resources and constraints shape its decisions.
The following are some of the most important things for Tribal leaders to understand about managing a Tribal health program.
1. The Health Program Is a Major Tribal Government Operation
A Tribal health program may employ many people, operate facilities, manage substantial budgets, provide clinical and public health services, administer Purchased/Referred Care, collect third-party revenue, and work with federal, state, and local organizations.
It works best when treated as a major Tribal government operation, with clear authority, accountability, financial controls, and management expectations.
2. More Money Does Not Automatically Mean More Health Care
Additional resources can make new services possible, but money does not automatically translate into more patient care. A new service may require staff, facilities, equipment, information systems, administrative support, billing capacity, and continuing funding.
Before adding a service, it helps to ask what it will take to start it and what it will take to sustain it.
3. Not All Health Care Dollars Are Interchangeable
Health programs may receive money from IHS, Medicaid, Medicare, private insurance, grants, Tribal appropriations, and other sources. These resources can have different purposes, restrictions, reporting requirements, and costs associated with generating and managing them.
Under P.L. 93-638 contracting or compacting, federal health funding becomes part of the Tribal government’s financial structure. The Health Director does not personally control federal funds. Tribal government establishes the financial and administrative framework within which the health program operates.
4. Purchased/Referred Care Is Not Unlimited Insurance
Purchased/Referred Care is an essential part of many Tribal health programs, but it is not simply an insurance plan that pays every outside medical bill.
PRC operates within eligibility rules, available resources, authorization processes, and other requirements. The program must manage those resources carefully while helping patients obtain necessary care that cannot be provided locally.
5. Eligibility Can Be Complicated
Who is eligible for services, and which services can be provided, can involve federal requirements, Tribal policy, residence, referral rules, and other factors.
Eligibility decisions need to be consistent and defensible. Political pressure to make individual exceptions can create problems for the health program and for the people who depend on it.
6. Health Care Personnel Are Difficult to Recruit and Retain
A Tribal health program cannot provide services without people. Recruitment and retention can be difficult, particularly for clinicians and other specialized positions.
Compensation matters, but so do supervision, workload, organizational culture, facilities, professional support, housing and community circumstances, and the ability to provide a stable work environment.
7. The Health Director Cannot Solve Every Problem
The Health Director is responsible for managing the program, but many problems require decisions or resources outside the director’s authority.
A director cannot create a specialist who is not available, build a facility without funding, change federal eligibility rules, or solve a Tribal government problem alone.
Accountability works best when it matches authority and resources. Tribal leadership can reasonably expect the Health Director to identify problems, recommend solutions, manage what is within the program’s control, and clearly explain what requires action elsewhere.
8. Good Health Programs Need Good Information
Leadership needs reliable information about access, staffing, services, PRC, eligibility, revenue, costs, quality, and community health.
Good information helps leadership understand what is happening and decide what to do. Large reports are not necessarily better reports.
9. Accountability Requires Clear Expectations
Accountability depends on two things: the Health Director knowing what Tribal leadership expects the health program to accomplish, and Tribal leadership knowing what resources, authority, and constraints affect those expectations.
Good accountability is not simply asking whether something went wrong. It means establishing clear responsibilities, reviewing results, identifying barriers, and making decisions about what needs to change.
10. The Health Program Belongs to the Community
A Tribal health program exists to serve the community. That means community members need appropriate opportunities to provide input about health priorities and the experience of receiving care.
Community input is not the same as management authority or Tribal Council governance. The challenge is to create meaningful ways for people to be heard while maintaining clear organizational responsibilities.
Questions for Tribal Leadership to Consider
- What are the most important responsibilities of our Health Director?
- Does the Health Director have the authority and resources needed to meet those responsibilities?
- What are the major financial constraints on the health program?
- Which resources are restricted or have specific purposes?
- What does our PRC data tell us about gaps in local services?
- Where are our greatest staffing and recruitment problems?
- What information does Council need to understand the health program without micromanaging it?
- What decisions belong to Tribal Council, and what decisions belong to management?
- How are community members given a meaningful opportunity to provide input?
The Principle
Good Tribal health governance requires a clear distinction between governing and managing.
Tribal Council sets direction, establishes policy, provides resources, and holds the health program accountable. The Health Director manages the organization, advises leadership, identifies problems, and carries out the program within the authority and resources provided.
The stronger that relationship is, the more effectively the Tribal health program can serve the community.