PROGRAM REPORT AND PLAN 
FOR 
INDIAN HEALTH 
FISCAL YEARS 1971 - 1975 
JULY 3 1 , 1969 
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 
Public Health Service 
Health Services and Mental Health Administration 
Indian Health Service PROGRAM REPORT AND PLAN 
INDIAN HEALTH 
CONTENTS 
Page 
I. Program Background - \ 
A. Program Objectives 5 
B. Program Operations . 30 
C. Evidence of Program Effectiveness 50 
D. Distribution and Recipient Data 59 
II, Budget Information 64 
III. Legislative Changes (recent) 66 
IV. Forward Plan 67 
A. National Goals, Needs and Program Objectives 67 
B. Program Requirements 90 
C. Budget Projection--Dollar Requirements to Meet the 
Needs at Both the Realistic Level and the Alterna- 
tive Level 106 
D. Legislation Requirements .....113 
APPENDIX I - Issues 
APPENDIX II - Listing of Proposed Projects 
According to Priority I. 
PROGRAM BACKGROUND PROGRAM REPORT AND PLAN 
INDIAN HEALTH 
I. PROGRAM BACKGROUND - INTRODUCTION 
History has given the Federal Government a unique relationship with a 
major segment of the Indian population in the United States. The basis 
for this unique relationship is deeply rooted in the treaties (approxi- 
mately 400) the Government entered into with various Indian tribes; and 
the numerous laws enacted by Congress for the benefit of Indians. 
It is through this relationship that the Government provides for the 
protection of Indian land and resources and for selected services designed 
to improve the quality of Indian life. 
There are currently over 600,000 citizens who identify themselves as 
Indians, Eskimos and Aleuts (hereafter referred to collectively as "Indians"). 
About 405,000 reside on or adjacent to Federal Indian reservations and in 
identifiable Indian communities in Oklahoma and Alaska, It is this group 
who fall under the aforementioned Federal relationship and participate 
in a variety of special Federal Indian programs, including the program of 
Indian Health Service. The remaining 200,000 Indians live on state 
reservations, mainly along the Eastern seaboard, and in towns and cities 
throughout the nation and do not maintain a special relationship with the 
Federal Government. When their social service and other needs are met, 
they are met through the normal channels serving all other citizens. 
Traditionally, the Bureau of Indian Affairs, Department of the Interior, 
served as the only organizational entity within the Executive Branch of 
Government to carry out special Federal programs for Indians. 2 
However, during the 1920's and 1930's other Federal agencies entered the 
Indian service field. For example, the Public Health Service began 
assigning physicians to work in the Bureau of Indian Affairs Health 
Services Division. Later on, predecessors of the Department of Health, 
Education and Welfare's Social Security Administration and Social and 
Rehabilitation Service began to extend benefits to persons who qualified 
and Indians were included. 
Multi-agency involvement with Indians and their problems was intensified 
during the 1950's. Responsibility for health services for Indians was 
transferred by Congressional action from the Bureau of Indian Affairs to 
the U.S, Public Health Service on July 1, 1955, resulting in the estab- 
lishment of the Division of Indian Health, now designated the Indian 
Health Service. Also, in the 1950's Federal Impact Aid for Education 
was extended to include Indian children attending public schools. This 
program is administered by the U. S. Office of Education of HEW. 
During the last decade, landmark legislation enacted by Congress authorized 
broad sweeping authorities calling for new efforts to alleviate adverse 
social and economic conditions of the disadvantaged citizens of the Nation, 
These new programs generally were made available to Indian people. 
In the field of health specifically, significant amendments were enacted 
by Congress to the basic Social Security Act authorizing new programs to 
meet health and medical needs of the aged and a large segment of the indigent 
and medically indigent population of the nation. Medicare and Medicaid, 
respectively, offer a potential health resource for Indian people. They 3 
pose a challenge in coordination and in public administration to Federal, 
State and local levels of government in extending these programs to 
Indians. 
As a result of these developments, the Indian field, which was once 
characterized by a single agency effort through the Bureau of Indian 
Affairs, is now characterized by multi-agency involvement; several 
major Federal departments are presently involved with an identifiable 
expenditure approximating $500 million in FY 1969. 
Because of these developments, most reservations show the imprint of 
other agencies such as the Office of Economic Opportunity, Department of 
Housing and Urban Development, Economic Development Administration, 
Department of Labor, Department of Agriculture, and Department of 
Health, Education, and Welfare, Thus, it is no longer possible or 
realistic for a single agency to develop broad-based program plans 
within a vacuum for the Indian community. An agency must take into 
consideration the entire spectrum of Federal, State, local and tribal 
governmental resources, along with those of the private sector, that 
have relevance to its program efforts. Trends and developments within 
given fields, such as health, must be noted in order to make appropriate 
shifts and adjustments in policy and program operations. 
The availability of new and expanded social and economic benefits for 
Indian people has served to ignite within them a renewed sense of 
responsibility and desire for greater involvement and participation in 
programs designed to improve their well-being. The opportunities to 
involve Indian people in the planning, operation and evaluation of programs 4 
is greater today than ever before. Opportunities exist also to place 
all or parts of various program activities under the direct control and 
administration of the Indian people. 
It is within this framework that the future plans for Indian Health are 
being developed in order to relate all health resources meaningfully 
and to relate health resources to other program efforts designed to improve 
the well-being of Indians (such as public housing programs, tribal com- 
munity action programs, tribal alcoholism control programs, tribal economic 
development programs. State and local programs), and to the existing oppor- 
tunities to place increasing health responsibilities under the direct 
control and administration of the Indian people themselves. I. PROGRAM BACKGROUND 
A. Program Objectives 
1. The program objectives of a comprehensive program for Indian 
health can best be defined in terms of an expressed mission 
and goal. 
The mission is to assure a total health services system for 
meeting the health needs of American Indians and Alaska Natives, 
The goal is to raise the health level of the Indian and Alaska 
Native people to the highest possible level. 
The objectives for achieving this goal are to be accomplished 
emphasizing Indian Alaska Native involvement and participation 
to the fullest extent with full utilization of available public 
and private resources. 
The objectives are 
(a) To reduce the mortality and morbidity of Indians by 
providing expanded and improved preventive health 
services, treatment of disease, and rehabilitative services. 
(b) To improve the physical environment. 
(c) To improve understanding among the Indians and Alaska 
Natives of health practices such as personal hygiene, 
nutrition and drugs and societal factors related to 
health such as housing and sanitation. BRIEF SUMMARY OF INDIAN HEALTH SERVICE LEGISLATION 
Indians--Hospital and Health Facilities—Maintenance and 
Operation Act, (PL 83-568) approved August 5, 1954, and effec- 
tive July 1, 1955, authorized the Surgeon General of the United 
States Public Health Service, under the direction and supervision 
of the Secretary of HEW, to maintain and operate hospitals and 
health facilities for Indians and to conserve their health. It 
also provides broad authority to provide a comprehensive health 
program such as public health nursing, health education, environ- 
mental health, maternal and child health (including family 
planning), school health, oral health, nutrition, accident pre- 
vention, mental health (including alcoholism treatment), and 
the conduct of communicable disease control activity with 
special emphasis on trachoma and tuberculosis. Public Law 83-568 
was enacted into law without an expiration date and did not 
specify any level of fund authorization. 
Surgeon General--Indian Sanitation Facilities Act, (PL 86-121) 
approved July 31, 1959, amended the provisions of PL 83-568 by 
authorizing the Surgeon General to construct, improve, extend 
or otherwise provide and maintain by contract or otherwise, 
essential sanitation facilities, including domestic and 
community water supplies and facilities, drainage facilities, 
and sewage and waste disposal facilities, for Indian homes, 
communities and lands. The Act also granted authority to 
acquire land and other interest and to make agreements with public authorities, non-profit organizations and agencies 
for the construction, improvement and extension of such sanita- 
tion facilities. Also authorized was the transfer of facilities 
constructed, to the Indian tribe, group, band or community 
involved. The Surgeon General is required to consult with 
or encourage the participation of the Indians in carrying 
out these provisions. Public Law 86-121 was enacted into law 
without an expiration date and did not specify any level of 
fund authorization. 
The Indian Health Facilities - Funds Act, (PL 85-151), approved 
August l6, 1957, authorizes the Surgeon General to provide 
financial assistance to public or non-profit organizations 
or agencies for the construction of community hospital beds 
for Indians from funds available for the construction of 
Indian health facilities whenever it has been determined that 
the health needs of the Indian are better met through such 
assistance. Public Law 85-151 was enacted into law without 
an expiration date and did not specify any level of fund 
author!zat ion, 
The Partnership for Health Amendments of 196?, (PL 90-17*0, 
Section 32*+, authorizes medical, surgical, dental treatment 
and hospitalization and optometric care for Federal employees 
and their dependents at remote medical facilities of the 
Public Health Service where such care and treatment are not otherwise available and provided that such services which 
may be furnished to Federal employees on a space available 
basis, priority being given to the Indian people served. 
The provisions of this act have not been implemented because 
of the fund and personnel restrictions under the Revenue and 
Expenditure Control Act of 1968, Public Law 90-36*+, which 
do not permit such services without limiting services other- 
wise available to the Indian people served. Part C of Title 
III of the PHS Act was amended by Public Law 90-17*+ Section 
328 to provide for the sharing of medical care facilities and 
resources on a reciprocal reimbursement basis. To date the 
provision of this law has not been utilized by the Indian 
Health Service (IHS), 
Public Law 90-17*+ was enacted into law without an expiration 
date and the level of authorization is limited only by the 
availability of service and space at the facilities desig- 
nated as remote. b. Other Department of Health, Education, and Welfare Legislation 
The Comprehensive Health Planning and Public Health Services 
Amendments of 1966 to the PHS Act, (PL 89-7^9)> for grants 
to any public or non-profit private organization to cover 
part of the cost of providing services to meet needs of 
limited geographic scope or of specialized regional or 
national significance. The grants may also be used for 
stimulating and supporting, for an initial period, new 9 
programs of health service. They may also be used to 
support the undertaking of studies, demonstrations or 
training to develop new methods or improve existing methods 
of providing health services. This program also provides 
for Area-wide grants, grants to States for comprehensive 
planning and project grants to assist in training, studies 
and demonstrations leading to improved or more effective 
health planning. 
The Social Security Amendments of 1965, (PL 89-97), Title 
XVIII, (Medicare) is available to Indians as it is to other 
citizens. This resource is treated as an alternate resource 
for health services for Indians. Because of the relatively 
small number of aged Indians and limited availability of 
other facilities, the impact on direct delivery and contract 
delivery has not been great. 
Title XIX (Medicaid) (under PL 89-9?) is also treated as an 
alternate resource for health care for Indians. However, 
Medicaid has not been implemented in all the States with 
Indian Reservations. Almost 38% or over 153,000 Indians 
live in States with no current Medicaid program, including 
Arizona and Alaska with high Indian or Native populations. 
Another 33$ or about 133,000 Indians live in States whose 
medical programs include only recipients under the 
categorical aid programs and do not include any health 10 
services for persons considered to be "medically needy." 
The Social Security Act, Title Vj h2 USC provides grant-in- 
aid to States for extension and improvement of services to 
crippled children. These services include locating crippled 
children and providing medical, surgical, corrective and 
other services for diagnosis, hospitalization and aftercare 
of such children. The IHS works very closely with the 
Social and Rehabilitation Service to assure that Indian children 
receive the benefits from this program. 
The PHS Amendments of 1968, (PL 30-57*0, provides health 
services for migratory workers. Some Indians come also 
within the scope of the migratory worker program. There 
have been coordinative efforts between the IHS and Community 
Health Service regarding provisions of health care to Indians 
who are migratory seasonal agricultural workers. 
Operating under the Public Health Service Act, Section 301 
and 303, the National Institute of Mental Health provides 
grants to agencies, institutions and individuals for applied 
research on new approaches to mental health problems and for 
training mental health workers. Since mental health is one 
of the areas of extreme iuportance to Indians, there is close 
cooperation between NIMH and IHS to develop methods for 
meeting the mental health problems encountered in the Indian 
population. 11 
Under the Fur Seal Act of 1966, (PL 89-702), the Secretary 
of Health, Education, and Welfare is authorized to provide 
medical and dental care to the natives of the Pribilof Islands 
with or without reimbursement as provided by other laws. 
He is also authorized to provide such care to Federal 
employees and their dependents and tourists and other 
persons in the Pribilof Islands at reasonable rates as may 
be determined by him. This law, which was enacted on 
November 2, 1966 carries no expiration date nor any level of 
authorization! however, the Act stipulates that the cost of 
such items related to the provision of medical and dental 
care shall be charged to the budget of the Secretary of 
Health, Education, and Welfare, 
The Menominee Indians - Grants Act, (PL 89-653), October 
lk9 1966, authorized a four year program (beginning with 
FY 1967) to assist the Menominee Indian people of Menominee 
County, Wisconsin, in a program of school aid, public welfare 
benefits, and health and sanitation services costs. 
The Heart Disease Cancer, and Stroke Amendments of 1965 to 
the PHS Act, (PL 89-239), which set up the Regional Medical 
Programs has been amended by the PHS Amendments of 19&8, 
(PL 90-57*0, to include grants to any agency or institution, 
or combination thereof, to assist in meeting the cost of 
participation in such program by any Federal Hospital« To 
date the IHS has not utilized the provisions of this law. 12 
The Social and Rehabilitation Service, through its Office 
of Juvenile Delinquency, operating under the Juvenile 
Delinquency Prevention and Control Act of 1968, PL 90~hk5, 
carries on programs designed to help States and local 
communities strengthen and improve their juvenile justice 
and juvenile aid systems, and to provide diagnostic, 
treatment, rehabilitative and preventive services to youths 
who are delinquent or in danger of becoming delinquent. 
The aspects of juvenile delinquency represents one manifesta- 
tion of the effects of poverty, cultural clash, lack of 
education and poor family life and represent a significant 
problem in the Indian population. The IHS, SRS, and NIMH are 
working together to seek solutions to these problems. 
c. Other Federal Legislation 
Department of Agriculture (USDA) 
The Commodity Distribution Program, 7 DSC helps to 
improve the nutrition of families in need of food assistance 
through the provision of packaged commodity food items to 
eligible families. The IHS works closely with USDA to make 
this program as beneficial as possible to Indians. 
The Food Stamp Program, 7 USC 2011-20253 makes provisions 
to improve the diet of low income households by expanding 
the purchasing power of eligible low income families. 
Indian families are encouraged to take advantage of this 
program and the IHS works with the USDA and Indian families 13 
to enhance the value of this program. 
Consumer and Marketing Service also operates the Supplemental 
Food program for Low Income Groups Vulnerable to Malnutrition. 
It has been determined that Indians receiving care from the 
IHS are eligible for this program. It provides supplemental 
food stuffs to infants, preschool children, prenatal, post- 
partum, and lactating mothers. 
Other programs provided by the Consumer and Marketing Service 
under the Child Nutrition Act of 1966 as amended by PL 90-30? 
are the School Breakfasts Program, The School Lunch Program, 
and the Special Food Service for Children. The School Break- 
fast Program grants cash to schools through State Educational 
agencies to help them provide breakfasts that improve child 
nutrition. Benefits are also available for children in pre- 
school activities. The School Lunch Program provides com- 
modity and cash grants to State education agencies to assist 
them in providing adequate school lunches. The Special Food 
Service for Children program provides, on a 3 year pilot basis, 
for cash grants to states to initiate, maintain or expand 
non-profit food service programs for children in service 
institutions. These programs reach school age children 
during the summer months in settlement houses, neighborhood 
houses and recreation centers. Pre-school children 
receive year round assistance in child day-care centers. 14 
Farmer’s Home Administration operates under the Consolidated 
Farmers Home Administration Act of 1961 as amended by PL 
This agency provides assistance to public or quasi- 
public bodies serving residents in open country or villages 
up to 5,500 population which are not part of an urban area 
to plan, develop and improve water and waste disposal systems 
The IHS has been working with this agency to improve 
sanitation on Indian reservations and in Indian homes. 
Department of Commerce 
The Public Works and Economic Development Act of 1965, Sec. 
301b Public Law 89-136, provides planning grants to assist 
the people of chronically depressed areas to help themselves 
develop sound long-range plans, strategies and development 
activities to overcome, in particular, substantial and 
persistent unemployment, underemployment and low income. 
The IHS has established a liaison with the EDA and there is 
developing cooperation between the agencies for a concerted 
effect to improve the life of the Indians, not only in health 
but in all aspects of daily life. A prime example of this 
is the Zuni Comprehensive Development Plan, in which IHS, 
Bureau of Indian Affairs and Economic Development Administra- 
tion all play a significant part. 
The Department of Housing and Urban Development (HUD) 
The Community Resources Development Administration, acting 
under the authority of the Housing Act of (Amended 1968) 15 
Section 701, makes grants to assist state and local officials 
in establishing and maintaining a comprehensive planning 
process, and improve the quality of land development. 
The Housing and Urban Development Act of 1965, Sec. 702, 
(PL 89-117), provides grants to construct community water 
and sewer facilities that are basic to efficient and orderly 
area-wide community growth and development. The IHS, HUD and 
Office of Economic Opportunity work c3.osely, for instance, on 
the provision of housing, including water and waste disposal,for 
the Indian people. 
The Demonstration Cities and Metropolitan Development Act 
of 1966, Sec. IOOU, (PL 89-75*+), provides grants and loans 
to assist the State of Alaska in providing housing for natives 
and other residents of Alaska whose incomes are too low to 
enable them to finance housing and related facilities they 
can afford. 
Department of the Interior 
Under Programs for Indians, 25USC, the Bureau of Indian 
Affairs (BIA) carries out the responsibility of the U.S. for 
providing to Indians and Indian tribes all of the options 
and opportunities that are available to Americans generally. 
This includes working with Indian Communities, other com- 
munities, the State and other agencies toward education for 
Indian children, elevation of Indian standards of living. 16 
development of Indian capability to manage their own affairs, 
promotion of political and social integration and fulfillment 
of the Federal responsibility for Indian trust property. The 
goal is to assist the Indian people to take their place in the 
social and economic life of the nation on the same basis as 
other citizens. There is a great deal of interagency coopera- 
tion between IHS and BIA. 
Office of Economic Opportunity (0E0) 
Under the Economic Opportunity Act, (PL 90-222), of 1964, 0E0 
carries on programs to aid in developing and carrying out com- 
prehensive health service projects focused on the needs of urban 
and rural areas having high concentration or proportions of poverty 
and marked inadequacy of health services for the poor. There 
is a growing cooperation between IHS and 0E0 in terms of 
program supplementation. Each agency recognizes the role of 
the other in supporting and carrying out programs designed 
to improve not only the health of the Indians, but their 
economic, social, and physical well being as well. Project 
Head Start and the Community Action Programs are good examples 
of program coordination at the basic level. 17 
3. Indicate quantification of outputs and show levels of last 
3 years. 
Direct Federal Health Services - Medical and Dental {h years) 
FY 
67 
FY 
68 
FY 
§2 
FY 
70 
Direct Care 
Patient Days 
Gen., Med. & Surg. 
Tuberculosis 
687,400 
63,480 
666,100 
67,270 
619,982 
54,839 
636,900 
42,000 
Outpatient Visits 
849,700 
926,600 
982,187 
1,050,000 
Contract Health Care 
Patient Days 
296,700 
272,3d* 
269,700 
264,600 
Outpatient Visits 
149,000 
167,000 
167,000 
167,000 
Public Health Nursing 
*PHN Services - Clinics 
91,950 
100,000 
100,792 
100,800 
PHN Services Schools 
75,000 
78,100 
77,352 
77,300 
PHN Services Office 
Visits 
49,000 
55,000 
56,250 
56,250 
PHN Services Home 
Visits 
122,200 
139,^00 
130,000 
130,000 
PHN Group Teaching 
Patient Services 
2,155 
2,1*50 
2,1*50 
2,1*50 
Dental Services 
Direct 
Number of Individuals 
Provided Preventive 
Procedures 
88,432 
91,637 
98,000 
98,000 
Number of Individuals 
Provided Dental 
Care 
117,326 
129,100 
136,000 
136,000 
Number of Dental 
Treatments Provided 
51*5,500 
613,100 
643,000 
643,000 
♦Public Health Nursing 
April 30, 1969 18 
Direct Federal Health Services - Medical and Dental (Continued) 
FY 
SL 
FY 
68 
FT 
§2 
FY 
JO 
Contract 
Number of Individuals 
Provided Preventive 
Procedures 
10,300 
8,700 
9,500 
9,500 
Humber of Individuals 
Provided Dental 
Care 
17,430 
13,065 
14,500 
14,500 
Humber of Dental 
Treatments Provided 
80,900 
68,700 
76,100 
76,100 
Sanitation Services 
Technical Assistance 
and Consultative 
Services to Families 
68,000 
129,000 
135,00C 
176,000 
Technical. Assistance 
and Consultation 
Services to 
Communities 
31,000 
41,000 
44,000 
47,000 
Field Medical Services 
Visits to Physicians 
Health Centers 
284,700 
306,400 
325,000 
330,000 
School Health Centers 
39,400 
38,200 
45,000 
48,000 
Other Clinics 
320,600 
302,100 
330,000 
347,000 
Health Education 
Clinic Services 
(individuals) 
13,261 
23,240 
35,550 
40,000 
Home Health Services 
(Visits) 
10,200 
17,000 
20,200 
22,000 
Community Services 
(Groups Serviced) 
253 
463 
626 
652 
Service Unit Staff 
Coverage 
36% 
ko% 
4 ($ 
52^ 
April 30, 1969 19 
Direct Federal Health Services - Medical and Dental (Continued) 
FY 
FY 
FY 
FY 
§1 
68 
62 
JO 
Hospital & Clinic 
Construction 
New or Replacement 
Hospitals 
1 
0 
0 
0 
Health Centers 
2 
3 
0 
3 
Health Stations 
12 
7 
0 
h 
Quarters Construction 
Number of Units 
20rj 
99 
2 
6 
Alterations 
Number of Alterations 
1o 
10 
lh 
k 
Community Facility 
IBS Participation 
0 
1 
2 
0 
Sanitation Facility 
Construction 
Number of Homes 
Receiving running 
water and adequate 
waste disposal 
2,350 
5,550 
8,030 
8,670 
Additional Homes 
benefitting from 
other sanitation 
facilities improve- 
ments 
3,800 
1,800 
3,000 
1,700 20 
4. Relate Objectives with PPB“' Structure 
The objectives of the Indian Health programs are compatible 
with the PPB structure in that one of the categories is 
’’Health Services for Indians," The applicable PPB Program 
Categories are: 
Code Program Categories 
2 HEALTH 
23 PROVISION OF HEALTH SERVICES 
2 3 3 Direct Federal Health Services 
2331 Health Services for Indians 
233110 Medical and Dental 
233120 Sanitation 
233130 Health Education 
233140 Other 
Also 
231320 Other Medical Assistance for the Poor 
2 1 2 Providing Facilities and Equipment 
2 14 Improving Organization & Delivery of 
Health Services (HPSC) 
242000 Program Direction and Management 
There are other Health Program Categories, e.g., Medicaid, which 
constitute alternate resources in the Indian health program; 
also Education and Welfare Program Categories which may impact 
on health related problems. 
* Planning-Programming-Budgeting 21 
The Program Budget Codes are: 
0390 INDIAN HEALTH SERVICES 
03 9000 Indian Health Services 
03 9010 Patient Care 
039011 Direct Care 
039012 Contract Health Care 
03 9020 Field Health Services for Indians 
03 9021 Sanitation 
03 9022 Dental 
039023 Public Health Nursing 
03 9024 Health Education 
039025 Field Medical Services 
039030 Special Assistance to the Menominee 
Indian People 
03 9090 Administration 
390390 Advance Reimbursements for Indian 
Health Services 22 
5. In what respects does the program attempt to prevent social 
problems rather than treat them and how can its preventive 
impact be Increased? 
The Indian Health program attempts to prevent social problems 
in three respects. The first is in prevention and early treat- 
ment of disease as a social problem. The second is in providing 
comprehensive health services to individuals and families within 
the context of their total physical and social environment so 
that problems related to health are prevented. A third way is 
to participate in the development and promotion of related 
services like education, welfare, law and order which are 
essential to maintenance of health programs. 
In the prevention of disease, emphasis has been placed on infec- 
tious diseases, accidents and mental disorders, including 
alcoholism, which are major causes of death and disability among 
Indians. Most of these conditions are associated with social 
relationships of the family and the community. An effective 
attack on these diseases, therefore, requires an attack on their 
social causes and consequences. Further movement in this direction 
is being sought in the current trial in the Indian Health Service 
of problem-oriented health records. This system, originally 
devised by Dr, L. L. Weed of Cleveland, has the potential for 
dealing with and thus preventing many of the patients' social 
and personal problems which bear on his illness. 
High priority has been given not only to the traditional preventive 
activities such as maintaining immunization levels, holding 23 
prenatal and well child clinics, family planning, and follow-up 
contacts of patients with tuberculosis or venereal diseases, 
but also to new and innovated practices such as focusing on 
the multi-problem family and the development of new approaches 
to community mental health programs utilizing the strength of 
the varied and different cultures of the various tribes. Educa- 
tion in social and physical aspects, both good and bad, which 
affect health is also stressed. 
It is extremely important that the Indian Health program, with 
its mixture of direct and indirect resources based on mutual 
understanding and respect of people, operate in accordance with 
the felt needs and desires of the Indian people. It is also 
important that the program be dependable without fostering 
dependency, be a promoter of change without creating resistance 
to change, and be coordinator and not a wedge between Indians 
and non-Indians. These objectives are sought through individual 
and group Indian participation as described in I.B.4, 
These preventive impacts can be increased in a number of ways. 
First, in respect to health problems, by continuing the direction 
toward preventive and field health services discussed in Section IV. 
Second, by insuring acceptable and accessible services to Indians 
in which they have structured the setting of priorities. In 
reviewing priorities it will probably be critical to give more 
attention to the social problem of male heads of households as to 
their state of health for general employment. Also, more attention 
could be given to earning roles for males in the health field. 24 
Finally, total self-fulfillment on the part of the Indian people 
requires total development in terms of their education, employ- 
ment, and environmental conditions. The Indian Health program 
fully recognizes this fact and the proposal to accelerate parti- 
cipation and coordination with all agencies concerned with human 
resource development is discussed in Section I.B. and Section IV, 
6. Indian Health Problems and Needs 
An indication of the problems and needs which must be considered 
in a forward plan for a comprehensive health services system for 
Indians (see Section IV.A.5.) is provided in the following 
extracts concerning health problems, health related problems 
and constraints; 
a. Health Problems 
(1) Mortality 
The latest available (1967) age adjusted mortality data 
is considerably higher than the general population except 
for heart disease, malignant neoplasms, vascular lesions, 
and certain diseases of early infancy. The higher ratios 
are as follows: 
Ratio-Indian to U.S, 
All causes of death per 100,000 pop 1.4 
Accidents 3.9 
Influenza and pneumonia (excl.newborn) 2.4 
Cirrhosis of liver 4.4 
Homicide 3,5 
Diabetes 2.1 
Suicide 2.1 
Gastritis 3.3 
Tuberculosis, all forms 8.0 25 
Moreover, the Indian and Alaska Native infant death 
rate per 1,000 live births was about 1.4 times higher 
than the U.S. all races rate of 22.4. This high rate 
is primarily due to deaths in the post-neonatal period 
when infants leave the hospital and return to the complex 
problems that accompany poverty. 
Approximately 1/5 of all Indian and Alaska Native deaths 
in 1967 were due to accidents, 1/4 to disease of the 
heart and neoplasms, and 1/7 to infective and parasitic 
and respiratory diseases. 
The life expectancy at birth for Indians and Alaska 
Natives is 64.0 as compared with 70.5 for the general 
population. 
(2) Morbidity 
Infectious Diseases - Large numbers of episodes of illness 
requiring hospital or outpatient care are due to infec- 
tious diseases and their residuals. These diseases include 
gastroenteritis, dysentery, influenza, tuberculosis, otitis 
media, trachoma, pneumonia, and common childhood communi- 
cable diseases. 
Dental Problems - Dental caries, periodontal disease, 
orthodontic conditions, and missing teeth comprise a 
major health problem afflicting Indian and Alaska native 
populations. The average school child between 6-17 years 
of age experiences more than six decayed teeth and the 26 
average number of unfilled decayed teeth per adult 
between the ages of 18-79 years is more than three 
times that for the general population. For each 1,000 
persons, on the average more than 400 dentures are 
required and about 240 persons are experiencing periodontal 
disease. 
Malnutrition and Mental Health - These health problems 
are discussed in the projects in the appendix and in 
greater detail in separate issue papers. 
Health Problems - 1967 
Indians United 
Notifiable Diseases (Per 100,000 pop.) in U.S. States 
Tuberculosis--new active 170 23 
Rheumatic Fever 22 2 
Strep Throat 2,943 229 
Hepatitis 294 21 
Measles 553 32 
Gonorrhea 770 207 
Syphilis 123 52 
Pneumonia 3,680 NR* 
Otitis Media 8,099 NR* 
Gastroenteritis 6,712 NR* 
Influenza 993 NR* 
Trachoma 1,077 NR* 
(* NR - Not reported.) 
b. Health Related Problems 
Health related problems or needs impacting upon the health 
status of the Indians or upon the effective delivery of 
services principally include: 
(1) Housing: The average family of five or six lives in a 
one or two-room house. 27 
(2) Sanitation: Even after construction in FY 1969, approxi- 
mately 46% of the estimated 73,500 Indian families will 
still lack running water and will have inadequate means 
of waste disposal. 
(3) Income: In 50% of the households the income is under 
$2,000 a year -- hardly enough to sustain life much less 
maintain it in a healthy condition. Part of this problem 
is a higher unemployment rate, as high as 80% in some 
areas. 
(4) Geography and Transportation: The problem of isolation 
of the Indian and Alaska Native because of these factors 
is discussed in I.D.3, 
(5) Communication: There is a problem of cultural, linguistic 
and psychological isolation in addition to the physical 
barriers. Consideration must be given to the differences 
between Indian and non-Indian cultures as well as to the 
many differences among the various Indian communities. 
Related to communication is the problem of literacy and 
educational levels and levels of understanding of good 
health practices. 
(6) Health Care Facilities: The problem with respect to 
facilities is a peculiar one for each location considering 
the facilities themselves or lack thereof and their 
capacity to meet program needs. Each hospital facility’s 
problem may be generalized as one or more of the following 
failures in meeting: 28 
(a) fire and safety codes, 
(b) minimal requirements of the Joint Commission on 
Accreditation of Hospitals, 
(c) standards of professional societies, e.g., American 
Academy of Obstetrics and Gynecology, and 
(d) space needs particularly for ambulatory care, 
public health programs and supporting services. 
Hospital needs are mostly replacement rather than for 
entirely new locations. Health Centers and Health 
Stations suffer the problems cited above but more impor- 
tantly are simply lacking where the services need to be 
delivered, i.e., where the people are. 
c. Constraints 
The non-dollar constraints that could inhibit meeting the 
Indian health goal and objectives including self-determination 
may be summed up as follows: 
(1) A nation wide shortage of health manpower to participate 
with the Indian people in planning, operating and evalua- 
ting services in order to meet an estimated population 
growth for Indians eligible for Federal Indian services 
from 405,000 to 440,000 in 1975. Some of the constraints 
of scarcity of manpower can be overcome as stated in 
I.B.7. Also see Forward Plan in IV.A.5. 
(2) Constraints which inhibit other governmental resources 
and non-governmental resources from assuming a larger 
share of health services for Indians (See I.B.2, and 3. 
for discussion and possible solutions). 29 
(3) General lack of knowledge as to the most effective 
method of delivery of comprehensive health services 
to rural, isolated or disadvantaged populations, 
(See national goals in IV.A,2, and Forward Plan in 
IV.A.5.) 
(4) Lack of specific authority to deploy resources to 
coordinate the provision of resources for the needs 
of urban Indians and other Indian groups, (See issues 
in the appendix.) 30 
B. Program Operations 
1* What is the basic rationale for Federal Government action 
in this area? 
As described in the Introduction statement, history has given 
the Federal Government a unique relationship with American 
Indians and Alaska Natives. The basis for this unique relation- 
ship is rooted first in the treaties and agreements the Government 
entered into with various tribes; second, the numerous specific 
laws enacted by Congress for the benefit of Indians; and third, 
in the extensive landmark legislation enacted in recent years 
calling for alleviation of adverse social and economic conditions 
of the disadvantaged citizens of the Nation. The principal legis- 
lation in this area is summarized in I,A.2. In some cases it 
has recently brought several Federal agencies directly and indirectly 
into the health field, e.g., OEO's Neighborhood Health Centers 
and Community Health Aides and EDA's water and sewer grant or loan 
programs. 
The rationale for the Federal Government being in the Indian 
health field is supported in four ways. First, in direct delivery 
of services including health; second, in financing the provision 
of services through parties other than the Federal Government; 
third, in encouraging the participation of other health resources 
in the program of improving the health of the Indian; and fourth, 
in supporting the movement toward more services coming under the 
direct control and administration of Indians. 31 
Because of the relationship of the Federal Government with 
the Indian people, the Government also carries out a unique role 
in insuring that these r.ourcevS of services to Indians are most 
effectively coordinated to optimize their benefits. 
2. What is the involvement of State and local government in this 
area? 
The Comprehensive Indian Health program operates as a system with 
three highly interrelated sets of resources and services; (1) Direct 
services (or the Indian Health Service), (2) Contract services (or 
services which the Indian Health Service contracts and pays for), 
(3) Alternate services (or services available to Indians but paid 
for by sources other than the Indian Health Service). 
State and local Governments either provide contract services or 
provide or support alternate resources, e.g., State hospitals 
or State contributions to Medicaid. The Federal Government, 
through other than IHS funds, is also involved in alternate 
resources, e.g.. Medicare. 
There is considerable variety in the involvement of State and 
local Governments from place to place in either the provision of 
services or support of alternate resources just as there is 
considerable variation in the impact of the Indian population 
in the 24 reservation States. 
Indian population on a percentage basis ranges from 0.17. in 
Florida to 17.67, in Alaska. In terms of total numbers, the 
impact ranges from 2,200 in Iowa to 97,000 in Arizona. Generally 
speaking, most States include Indian populations in their total 
counts for purposes of Federal aid programs. 32 
State and local public health programs, e.g., dental, public 
health nursing, environmental health, and immunization programs, 
have generally been available to Indians. Sometimes Federal 
supplemental funding has been necessary because of problems of 
additional or supplementary needs of Indians caused by geographic 
dispersion, cultural barriers, unmet health needs and insufficient 
non-Federal resources. 
a. Federal, State, and local government carrying their proper 
share of financial and administrative burden? 
As with the matter of involvement there is considerable 
variety among the individual States and communities, their 
economies, and abilities to provide services. In general, 
the lag in the health status of American Indians and Alaska 
Natives as compared with the general population suggests that 
the collective programming of services is inadequate. 
In regard to the respective shares of the financial and 
administrative burden, State and local governments appear to 
feel that Indian problems are Federal problems and not local 
ones. Because of this. State and local governments tend to 
demur in terms of services for Indians in the expectation 
that the Federal Government will provide for the health needs 
of their Indian citizens. 
b. What action is necessary for local and State governments to 
assume greater responsibility? 
What is needed is the creation of true "partnerships for health" 
through comprehensive planning at the community level within 
the context of the larger area, regional, State, and Federal 
programs for Indian health and resource development. 33 
There is concurrent need for clarification of relationships 
of State and local governmental units to tribal governments 
and their respective responsibilities in the provision of 
services to meet the health needs of Indians. 
The actions needed within the comprehensive planning concept 
at the comm\mity level are described in greater detail in 
the Forward Plan in Section IV. These actions consist of 
(l) determining and obtaining the combination of health 
resources which can best meet the Indian health needs, (?) 
achieving better organization and delivery of health services 
in general, (3) achieving more viable local economies, and 
(U) increasing the awareness of all components starting with 
Federal agencies of the need for a priority of commitment 
toward Indian problems. 
3. What is the present role of non-Governmental participation in 
this area? 
a,. Profit making institutions? 
As cited in I.B.2., the comprehensive Indian health program 
includes contract health services paid for by IHS. These 
services are provided by physicians, dentists, other health 
practitioners, consultants, laboratories, hospitals (mostly 
non-profit) and other institutions. Contract health services 
in the Indian Health Service budget have grown from $7.9 million 
in FY 1956 to $17.8 million in FY 1969. While the rise in 
budget levels reflects significant increases in costs, it reflects 
more importantly a concerted effort to assure that high quality 34 
comprehensive and speciality care services are provided in 
a most effective and accessible manner. 
The roles of institutions which are clearly considered to 
be profit-making are largely in the area of administrative 
services needed to support IHS direct care delivery and the 
contract health resources. Profit making institutions and 
individuals furnish medical supplies, food, utilities and 
services (e.g., laundry); construction of health care and 
sanitation facilities; and other contract services, e.g. 
the IHS Management Information System (MIS), 
Included in these groups are Indian Tribes, Tribal Councils 
or corporations with whom contracts have been made for 
materials and/or labor, e.g., construction of housing and 
sanitation facilities. Also see I.B.4, 
b• Non-profit institutions and associations including community 
groups of all kinds? 
(l) Institutions 
An example of the association with institutions is Public 
Law 85-151 through which funding has been provided for the 
addition of 129 beds in community hospitals in 17 locations 
to insure the availability of, enough beds for both Indian and 
non-Indian use. Ambulatory facilities for health services 
for the Indian people have also been provided in a few com- - 
munity hospitals. 35 
(2) Local Associations 
Specialized contracting has been developed in several 
instances with local non-profit groups, such as local and 
State TB associations, foundations and charities to provide 
specialized services on a cost sharing basis. In some 
locations church organizations are concerned with Indian 
health and general well-being. Several universities have 
conducted training courses in health program management and 
have performed various special studies associated with Indian 
health. 
(3) P3.anning Agencies 
Health needs of Indians are taken into account in varying 
degrees by local, area, and regional planning groups such as 
in the Hill-Burton, Comprehensive Health Planning (CHP), and 
Regional Medical Programs (RMP). Both IHS staff and repre- 
sentatives from the Indian community are serving as members 
of these planning or advisory bodies in some cases. 
(U) Professional Associations and Advisory Groups 
Advice and consultation is provided by professional associa- 
tions and advisory groups and individuals to the Indian Health 
Service, such as: 
(a) —Indian Health Advisory Committees (at both the IHS 
Headquarters and Area levels with a goal of 100% Indian 
membership). 
(b) —Indian Health Advisory Committee of the American 
Academy of General Practice. 36 
(c) Health Advisory Committee of the American 
Academy of Pediatrics. 
(d) —American Dental Association Committee on Indian 
Health. 
(e) —American Hospital Association Committee on Indian 
Health. 
(f) -Indian Health Sub-Committe of the American Public 
Health Association Committee on Medical Care Administra- 
tion. 
(g) —Association of State and Territorial Health Officers 
Health Services Administration Committee - Subcommittee 
on Indian Health. 
(h) --Indian Health Committee - Conference of State 
Sanitary Engineers. 
(i) —Indian Health Planning Advisory Committee of the 
American Pharmaceutical Association. 
c, Individual. Volunteers 
The following are exemplary efforts of individual volunteers: 
Candy-Stripers (teen-age volunteers), Red Cross Grey Ladies, 
and individual private practitioners, (e.g., members of the 
American Academy of General Practice) who accept assignments 
for periods of time, Indian families and friends also assist 
in overcoming the problems of deficiencies in transportation 
means or funds. 
Recognition of the value of these services came in the recent 37 
amendment to the PHS Act which permits some return of services 
to volunteers, e.g., meals. 
d• How can the role of each of the above in this area be increased? 
and 
e. Can all or any part, however small, of this program be spun off 
to any of the above» If so, how? 
Increasing the role of profit malting or non-profit institutions 
and spinning off more of the delivery of health services is 
basically dependent upon obtaining new and better combinations 
of the partnership in the Indian health services system, namely; 
direct resources, contract resources and alternate resources. 
In some cases contract or alternate resources will have to be 
created and/or economic development will be necessary to support 
them. That partnership process as described in Section IV will 
require that the possibilities for non-Governmental roles be 
created, be stimulated, be made known, be supported and that 
planning, education, and communication be used to overcome the 
constraints of; 
(1) financial and administrative mechanisms 
(2) community resource availability and quality 
(3) knowledge and attitudes on the part of the community 
(h) knowledge of alternate resources on the part of IHS staff 
(5) acceptance by the communities of their responsibilities 
(6) acceptance by the Indians of contract and alternate 
resources. 
Increasing the role of the Indian community is discussed in 35 
What is the role of the client or local community population 
in the program and how can it be strengthened? 
a, Individual participation 
In addition to providing volunteer services described above, 
individual Indians make valuable contributions to the program 
through employment in the IHS in a variety of positions such 
as registered nurses, nursing assistants, sanitarians, health 
educators, administrative officers, health records technicians, 
and food service workers. Indians also participate as trainees 
in a number of these job classifications and others such as the 
IHS School of Practical Nursing in Albuquerque, New Mexico. 
Indian employees are invaluable in reducing language and 
cultural barriers and providing understanding to the other 
IHS staff and the community. In addition, the employment of 
Indians is vital (sometimes indispensable) to the economy of 
the Indian community. 
The concept of Indian health personnel promoting communica- 
tion has been extended to the Community Health Representatives 
(CHR) and Alaska Native Community Health Aides (ANCHA) Programs. 
CHR's and ANCHA*s are tribal employees and receive only 
professional direction from IHS employees. These programs 
are designed by and are under the control of the tribes and 
IHS contracts with them for the provision of services. 
The value of individual Indian participation can be strengthened 39 
in several ways such as: (See Section IV and Projects 
in Appendix II). 
(1) Early introduction of more Indians to prepare for health 
careers, 
(2) Increased commitment to and execution of the policy of 
equal employment opportunity for Indians. 
(3) Creation of career ladders in employment. 
(k) Concentrated development of Indians for management, 
planning and decision making positions in IHS. 
(5) Expansion and extension of the CHH and ANCHA programs. 
As noted in I,B,3.b. above, individual Indians participate 
as representatives on IHS Headquarters and Area Advisory 
Committees and on State or regional planning bodies. 
b. Indian Participation 
Indian organizations and Indians in an organized way also 
make invaluable contributions to the Indian health program, 
for example: 
(l) Numerous hours have been provided through Tribal Health 
Coranittees, Boards of Health, health associations, e.g., 
the Lakota TB and Health Association and other Indian 
governmental groups in analyzing health problems and 
in planning and evaluating health programs. Indian 40 
participation in the planning, implementation, and 
evaluation of the IHS program is a requirement. 
(2) A part of the housing improvement program on Indian 
reservations is designated as self-help. The same 
designation could be applied to the IHS sanitation 
programs in which Indians assist in providing materials, 
labor, and assume operation after completion as a municipal 
service. 
(3) Several tribes,e.g., Zuni, Warm Springs, and Northern 
Cheyenne have undertaken comprehensive development plans 
which include health resources. Many tribes have pro- 
vided the necessary collateral for obtaining loans for 
development projects, some of which directly affect 
health. 
(4) In addition to the CIIR program, various services and 
supplies are purchased from tribes such as computer 
services from the Navajo in further support of the 
Buy-Indian Act. 
Indian participation can be strengthened in a number of ways, 
e.g. : 
(1) Issuance of policy guidelines for Indian participation 
in IHS programs. 
(2) Establishment of model Boards of Health and other 
participatory mechanisms and evaluate the question of 
authority vis-a-vis advisory roles. 41 
(3) Providing technical assistance and support, including 
grant authority for IHS to stimulate comprehensive 
planning and development. 
(U) Improving liaisons locally and at the Headquarters 
level with agencies concerned in comprehensive develop- 
ment programs and insuring IHS participation in them. 
(5) Expanding procurement of services from Indian communities 
including development of facilities which could be 
leased under Indian ownership and operation. 
5. In attempting to meet current social needs. what new social and 
economic problems may be created by this program? 
Reducing the gap in the health status of Indians as compared 
with the general population will tend to have several results. 
First, more of the scarce health manpower will probably be 
required. Second, a greater awareness on the part of Indians 
of the value of improved health status will tend to create a 
demand for more services. Third, there could occur a gap between 
the achievements in the health field and other social, educational 
and economic developments while all these developments are needed 
for a productive life of self fulfillment for Indians. 
The first two problems can be reduced by better organization and 
delivery of services and by the development of new kinds of manpower; 
the last problem by more coordinated planning. 
The IHS delivery program could possibly contribute to social 
problems by acting out of context with the people it serves; 
however, the program described under Indian participation above 
and in Section IV is intended to prevent such a problem from 
occurring. 6. When, if ever, can Federal Government participation in this 
area be phased out? 
42 
The answer to this question will vary in line with the services 
rendered to the approximately 405,000 Indians who comprise some 
260 different tribes residing in or near some 250 reservations 
within the 24 reservation States. Several not mutually exclusive 
things would seem to be necessary before phasing out can occur as 
follows: 
a. Indian consent, willingness and preparation to assume direct 
control and administration of the various health program 
activities now administered by the Federal Government or to 
replace it with another private or public resource. 
b. Recognition by local communities and governments of Indian 
needs and provision of systems of cooperative planning, pro- 
gramming and evaluation which include Indian needs. 
c. Adequate administrative capability and financial support 
from income within the Indian community or from public or 
private sources to attract and maintain health care resources. 
d. Health status levels among Indians comparable to those of the 
general population in communities which are adjacent to 
reservation areas or the commitment of the additional resources 
needed to arrive at such levels; comparable commitment in other 
areas affecting health, e.g., housing and sanitation. 
7. a. To what extent is the program attempting to provide models 
and experiments for new ways to attain national goals? 
The Indian Health Service by and with the consent of the 
Papago Tribe has an operations research program which is 
probably unique in the Federal Government and private 43 
industry. Utilizing as a base a group of approximately 
10,000 Papago Indians, the service is developing modeling 
systems applicable to the provision of health care which 
should serve as prototypes for the health care delivery 
systems of rural and ghetto areas as well as the urban 
areas of our country. New methods and techniques for health 
care delivery, reporting systems, manpower utilization, and 
other pertinent studies are being developed in a relatively 
controlled environment to provide new insights into the 
improvement of health care planning, programming, implementa- 
tion and evaluation. Efforts in this regard are being 
coordinated with the National Center for Health Services 
Research and Development through an Inter-departmental 
committee on Health Services Research and Development. 
Indian tribes and communities themselves are conducting some 
programs which could be developed into models such as in the 
areas of alcoholism, senior citizens home, and nutrition. 
b. & c. To what extent do obsolete rigidities hinder progress in 
the program area and what can be done about it, as for 
example: 
(1) In certification requirements: 
The problems of certification or licensure requirements 
which plague the health field in general constitute a 
double problem in areas where Indians live. In addition 
to certification and licensure problems, there are simply 
fewer people to undergo certification in areas where 
Indians live. In general such requirements are imposed 
for logical control reasons although the requirements 
should be reviewed more frequently and be altered to provide for new levels of personnel. V/here 
required IHS should seek waivers of certain educational 
and licensure requirements from appropriate professional 
and governmental bodies. It would also be helpful 
to be able to support the upgrading of Indian employees 
in particular so as to be eligible for certification. 
(2) In inhibiting substitution of sub-professional 
personnel; 
It is a certain matter that the usefulness of professional 
health manpower can be extended through the use of more of 
new types of health personnel. Certification limitations 
for health professionals contribute to inhibiting 
further progress. 
One way which the Indian Health Service is overcoming 
these limitations is to develop, test and implement 
new health personnel roles, in concert with the 
professional societies concerned. Examples of new 
health occupations and/or expanded functions include: 
Community Health Representatives, Dental Auxiliaries, 
Social Service Associates, and Accredited Record 
Technicians. 
(5) In absence of competition: 
There is an absence of competition in terms of the 
numbers of health and other professionals who are 
available to compete for jobs. This shortage or 
lack of people competing is engendered by the number of spaces available in schools because of funds 
or entrance requirements. The matter of entrance 
requirements is a particular barrier to Indians who 
have been economically or culturally excluded and who 
are increasingly required for programs such as those 
of IHS. 
The problem of entrance requirements, career ladders, 
competition for scarce personnel, and working conditions 
which inhibit attraction of personnel within the Civil 
Service system requires greater scrutiny. Also needed 
is alleviation of the arduous task to change classifications, 
grades, or establish new jobs within that system. An 
example of this inhouse problem is the entrance requirements 
for management interns and related administrative training 
positions which are of critical concern for the Indians 
in their progress toward self-determination. 
An even more striking example is the existence of require- 
ments in the Government Employees Training Act of 1958 
(see Section IV-D) for which exceptions for Indians 
has been requested. These requirements, for example, 
represent roadblocks for the minority employee who 
either lacks the "paper" qualifications for training 
or is not in a professional category which qualifies 
for further development. In the case of IHS nearly 60% 
of the employees are Indians while only a minute 
percentage are in professional and managerial positions. Those Indians Who are providing services do not 
have to overcome cultural and social barriers and 
provide the critical link in IHS providing services with 
the people it serves. Yet these same Indians face 
unwaivable paper barriers to advancement and have to 
stand back while the system adds to the capabilities 
of those who somehow meet the initial paper qualifications. 
(U) In introducing more Indians to health careers and 
occupations: 
Although the progress in this area is not so much 
hampered by obsolete rigities, the progress has been 
slow because of general lack of educational opportunities 
and subsequent loss of employment opportunities. If 
the Indian is going to have a voice in his own destiny, 
he must have skills and knowledge necessary for maximum 
contribution and participation. The Indian Health Service 
has led the way in encouraging Indian participation 
in developing policy, planning, implementation, and 
evaluation of program. This progress should be 
complemented by taking steps to develop Indian manpower 
to its maximum potential. 
The accomplishments to date point toward a beginning of 
achievement of increasing the number of Indians in all 
roles of health manpower. As a matter of accomplishments 
IHS has: 
(a) Achieved an employment level of nearly 60$ of its 
employees being of Indian descent. Some of these include positions such as Area Executive Officer 
or Financial Management Officer, Deputy Area 
Director, etc. 
(h) Instituted the Indian Career Development Program 
whereby Indians are and have trained for administrative 
positions in Indian Health Service. 
(c) Identified Indians are who physicians so they can 
organize to encourage other Indians to enter the 
health field. Indian physicians have been contacted 
and are in the process of organizing. 
More could be accomplished through IHS expanding its 
coordinator and stimulator role such as: 
(a) IHS Training Branch serve as a clearinghouse to 
gather and distribute information to Indian people 
on health professions and allied health fields 
through: 
1. Encouraging and promoting health institutions 
to accept more Indian students through more 
flexible entrance requirements. 
2. Following up with Indian students regarding 
problems, career questions, employment 
possibilities and information where further 
training and financial assistance can be obtained. 5. Encouraging tribal councils to organize 
educational activities such as to develop their 
own training centers with IHS and BIA assistance 
k. Identifying other Indian health professionals 
(dentists, professional nurses, sanitarians, 
pharmacists, social workers, etc.) so they too 
can assist in encouraging other Indians to enter 
the health field. 
5. Supply information, literature and advice on 
health training to Indian communities. 
6. Coordinating their training and educational 
activities — colleges, tribes or community, 
governmental agencies, universities, training 
centers, etc. 
7. Expanding the Indian Career Development Program 
whereby Indians are trained for administrative 
positions in IHS, and 
8. More actively recruiting Indians. 
(h) IHS actively support development of health careers 
curricula at Indian Community Colleges and 
Indian Training Centers through: 
1. Providing necessary consultation in health 
curricula development. 2. Assigning staff as advisors, resident 
faculty or Department Heads as may be requested, 
3, Examining IHS training programs for possibility 
of converting or expanding (IHS) training 
programs to more advanced or expanded function, 
as more Indians receive training in the basic 
health skills (LPN, X-ray, etc.) from their own 
training centers or facilities. (The idea is to 
(a) prevent duplication and (b) complement 
the tribal or Indian effort.) 50 
C. Evidence of Program Effectiveness 
1, What is the evidence that the objectives, discussed above, are 
really served by the program? 
(a) The Indian Health Program was transferred to the Department 
of Health, Education, and Welfare from the Department of 
Interior in 1955* The health status of the Indian and 
Alaska Natives was quite different from what it is today. 
As a result of continued and increasing support of Congress, 
assistance from private and governmental agencies and 
cooperation of Indian and Alaska Native leaders, the Indian 
and Alaska Native people have responded well to the health 
program efforts. Admissions to PHS Indian and contract 
hospitals have increased percent since 1955 from about 
50,000 to a record high of 92>000 in FY 1968. The rate of 
increase in later years has been at a lower level than 
earlier years indicating a potential leveling off. Out- 
patient visits made to hospitals, health centers and field 
clinics have more than tripled; and the number of dental 
services provided has almost quadrupled. 
Tuberculosis, once the number one scourge of Indians and 
Alaska Natives has been drastically contained. Tuberculosis 
death rates have declined markedly since 1955* The 
Indian, Alaska Native, and U.S. All Races rates of U7.39 
157.5, and 9,1 declined 66, 89, and 6? percent to a rate of 
l6.?, l6.6, and 3.5, respectively in 1967. Even though 51 
the rates declined markedly, Indian and Alaska Native rates 
were still over four times as large as the U.S, All Races 
rate. In 1956 for example, the Indian Health Service had 
3,606 tuberculosis admissions to PHS Indian and contract 
hospitals. In fiscal year 1966, there were only 859 
tuberculosis admissions. This represents a decline of 76 
percent in tuberculosis hospital admissions. New active case 
rates of tuberculosis among Indians and Alaska Natives also 
have been dramatically reduced. They are down 33.6 percent 
since 1962. 
The infant death rate among Indians and Alaska Natives 
combined declined about 48 percent between 1955 and 1967, 
from 62,5 to 32.2 per thousand live births. Over the same 
period, the U.S. All Races rate dropped 15 percent. In 
1955 the Indian and Alaska Native rate was 2.4 times as 
large as the U.S. All Races rate. In 1967, in spite of 
the significant improvement mentioned above, it was still 
1.4 times as high as the U.S. All Races rate. The Alaska 
Native rate fluctuated between 18 and 19 percent above the 
Indian rate over the 13 year period. Although still high, 
the Alaska rate declined 26 percent between 1955 and 1967. 
The death rate among Indians and Alaska Natives from 
gastritis, duodenitis, enteritis, and colitis, except 
diarrhea of the newborn, has declined over 60 percent 
since 1955. The U.S, All Races rate has dropped just 52 
19 percent in the same period, but is at a much lower level. 
In 1955, the Indian and Alaska Native rate was eight and 
one-third times the U.S. All Races rate and in 196? it was 
almost four times. 
In addition, life expectancy for Indians and Alaska Natives 
is years as compared to 70.5 for the general population. 
In 1950 the Indian life expectancy was 60.0 years and that 
of the general popuiation, 68.2 years - the gap is narrowing. 
The measles immunization program initiated in the fall of 
1963 is having a favorable effect. A marked decrease in 
the number of reported cases of measles among Indians and 
Alaska Natives has occurred in over the past several years. 
Provisional data for 1968 indicates that the number of 
reported measles cases dropped to about 315 cases in 1968 
from almost 2,000 in the previous year, continuing the down- 
ward trend since 1963 when 5,600 cases were reported. It 
would seem that with continued surveillance, virtual 
sradication of the disease is within the realm of possibility 
In 1955, there was only a small health staff, primarily, 
physicians and nurses. Today, there are almost twice as 
many full-time and part-time employees. There are now, for 
example, three times as many physicians and dentists serving 
the program, along with other categories of health personnel 
such as pharmacists, medical social workers, nurses, health 53 
educators, engineers, sanitarians and nutritionists who 
have been added through the years. 
In 1955, medical facilities were inadequate both in terms 
of number and quality. Since then 12 hospitals, 11 health 
centers and 47 field health stations have been built and 
major alterations have been made at 11 other facilities. In 
1965 only three IHS hospitals were accredited by the Joint 
Commission on Accreditation of Hospitals; in 1969 there are 
18 hospitals accredited. Through Public Law 85-151, 129 beds 
have been funded in 17 community hospitals to meet Indian and 
Alaska Native needs. A 200 bed medical center is now under 
construction at Phoenix, 
Since passage of Public Law 86-121 in 1959 enabling con- 
struction of sanitation facilities, projects have been 
authorized to provide new or improved water supply and/or 
waste disposal facilities for some Indian and Alaska 
Native families through fiscal year 1969. 
(b) One continuing evaluation tool is applied each year as an 
ongoing measure of progress. This is the "Q" index, which 
is one measure of the effectiveness of a health program 
and is an indicator of health status level. This index 
measures time lost from normal activities in terms of 
mortality, morbidity, and disability days. Health 
index values show status or change in health problems and 
lower values indicate a less severe problem relative to 
those with higher values. 54 
'Q" values are used to establish historical patterns and 
in light of past experience, project trends and new require- 
ments in medical service. An anticipated value for future 
health status is computed for each new planning period. 
As one example to illustrate how this evaluator is used, the 
following material is taken from a recent study of two sample 
disease classifications. 
Infectious and Parasitic Diseases (l) 
The diseases constituting this health problem have a 
great impact on the American Indian and Alaskan Native, 
much more so than on the general population of the U.S. 
This remains the case, in spite of continuing improve- 
ment in the treatment of the many diseases making up 
this category. The American Indian and Alaskan Native 
still suffer from greatly depressed socio-economic con- 
ditions involving crowded, sub-standard housing, poor 
nutrition, poor sanitation, inadequate and unsafe water 
supplies and waste disposal. These conditions adversely 
affect health and improvements in them should contribute 
to better health. 
Health Objectives 
The Service has as an objective, the improvement of the 
Health Index from 272 in FY 19&9 to 258 in FY 1970. 55 
Service Objectives 
Anticipated outpatient visits will increase from 196,300 
in FY 1969 to 198,400 in FY 1970. Hospital days are 
expected to decrease from a level of 148,900 in FY 1969 
to 134,400 in FY 1970, The number of hospital admissions 
is expected to decrease slightly from about 4,800 in FY 
1969 to 4,700 in FY 1970. 
INFECTIVE AND PARASITIC DISEASES 
Fiscal Years 
Diseases of the Respiratory System (VIII) 
Diseases comprising this category including those of 
pneumonia and influenza, constitute a major cause of 
morbidity and mortality among Indians and Alaska Natives, 
Although deaths from these diseases have declined steadily 56 
in recent years, they still remain considerably higher than 
in the general population. As the average age of the popu- 
lation advances, these diseases of the respiratory system 
assume increased importance as many result in chronic 
residual conditions such as chronic ear problems. 
Health Objectives 
The health objective for this category is to improve the 
Health Index from 272 in FY 1969 to 267 in FY 1970. 
Service Objectives 
The anticipated number of outpatient visits will increase 
from ,h00 in FY 1969 to *+35,900 in FY 1970. Anticipated 
hospital days will decline from 127,300 in FY 1969 to 
126,925 in FY 1970, Hospital admissions will remain 
essentially stable at about 15,000 in FY 1970. These data 
reflect a measure of success of the field medical program 
in terms of early case finding, early diagnosis and treat- 
ment and increased use of outpatient facilities. 
RESPIRATORY SYSTEM DISEASES 
Fiscal Years 57 
Summary 
The diseases and conditions which comprise ICDA classifi- 
cations I and VIII are primarily those which are com- 
municable in nature. Much of the work associated with the 
care and treatment of these diseases can be supplemented 
through increased emphasis on preventive types of services 
provided for the Indian and Alaska Native population in their 
environment. Indications are that for program actions to 
be successful in terms of acceptance and utilization, there 
must be tribal and native involvement and participation. 
To this end the Indian Health Service is developing a program 
for the training and utilization of Indian and Native 
community health representatives. Although a limited 
number of CHR1s have been trained so far, their use has 
been demonstrated as a valuable adjunct to the provision of 
services by health professionals employed by the Indian Health 
Service. 
2, Does the program provide for adequate monitoring and evaluation 
of performance and d.o these affect program administration? 
Use of the numerical index of health status related to specific 
disease classifications allows for continuing monitoring and 
also for comparing needs with administrative practices. Through 
use of the performance budget concept of administration, one can 
link the most pressing health needs with those programs designed 
to meet specific needs. It is not always feasible to expect 58 
reduction in disease incidence commensurate with the dollars 
devoted to the prevention and treatment of such diseases. However 
a cause and effect relationship frequently exists or can be 
reasonably assumed. The measuring techniques now employed permit 
identification of those program activities which are expected to 
be most cost-effective in terms of elevating the health status 
of the population we serve. 
3. Should the program be consolidated with similar programs else- 
where within or outside of DHEW? If not, why not? 
The Indian Health Service is unique because of its specific 
target population and because of the specialized nature of the 
service it performs. The peculiar geographical conditions under 
which much of the Indian population lives precludes the use of 
most non-Indian health facilities which might otherwise be 
utilized. Where necessary, IHS uses other government and 
private health services in lieu of building duplicative facili- 
ties and retaining medical specialities in scarce supply. As 
appropriate, IHS draws upon, and also provides resources to the 
Bureau of Indian Affairs, the National Institute of Mental 
Health, and other providers of direct health services within the 
Health Services and Mental Health Administration. There exists 
also a large degree of inter-departmental cooperation in 
coordinating efforts of various agencies to bear on the problems. 59 
D, Distribution and Recipient Data 
1. If State-grant program— present tabular listing of distribution 
by State (dollars and percent). Relate to best measure cf State 
need and evaluate distribution formula. 
This question does not apply to IHS. 
2, Who gets how much (percent)? 
By target group of recipient? 
a. The American Indian and Alaska Natives are the target group 
recipients of the services of the IHS and 100$ of the 
appropriated funds are directed to their health care. 
b. By control and type of institution? 
No applicable. 
c. Indicate source and validity of data. 
The source of the above data arises from the legislative 
authority under which the Service operates. Since there is 
only one target group involved, the validity of the data is 
self evident. 
3. In what geographical area does the program have its principal 
impact? 
a. Urban or rural? 
The programs of the Service have their principal impact in 
rural areas of the Western States and in Alaska, 
b. Region of United States? 
The activities of the Service are carried on in the 23 60 
23 reservation States in which the recipient popula- 
tion lives and also in the State of Alaska where a major 
portion of the programs are carried out for the Eskimos, 
Indians and Aleuts living there. 
c. Should the target area be broadened or otherwise changed? 
The target area should he broadened to include urban locations. 
As Indians and Alaska Natives migrate from the reservation 
areas which are essentially rural, to more urbanized areas, 
many of their already existing health problems are compounded. 
This is happening to an increasing number of people as 
employment relocation projects undertaken by BIA, and the 
lure of better employment and living conditions, continues 
to attract the Indians to cities. Once there, they find 
themselves in a strange environment, with little knowledge of 
where or to whom to turn for help. Often the municipality 
refuses to provide necessary services for them. These Indians 
and Alaska Natives still retain their eligibility for health 
care services, but heretofore, the Service has not been able 
to mount a program for these Indians in an urban environment. 
U, a. Is the program defined to serve a particular target popula- 
tion? If so, what population? 
The programs of the Indian Health Service are defined for a 
target population group consisting of American Indians and 
Alaska Natives who reside on or adjacent to Indian reservations 
and in identifiable communities in Oklahoma and Alaska. 61 
b. Does the program in fact serve that group? 
Yes. 
e. Is the target papulation too broad in light of budget 
restraints? 
While the target population is not too broad, budget 
restraints have limited capacities to provide services in 
the quality and quantity necessary to fully meet needs. 
d. What groups not served by the program are unable to buy or 
otherwise obtain similar services elsewhere? For example, 
the working poor? 
There are several groups receiving diminished care or none 
at all who are unable to obtain care elsewhere. Primary 
among these groups are Indians and Alaska Natives living in 
extremely remote areas not adequately served by IBS and not 
having access to any other medical assistance. Present 
resources do not permit building facilities at every location 
needing one. Present staffing levels permit only itinerant care 
at some locations. At some of these locations no medical 
care whatsoever is available, at others only minimal care can 
be given. 
Another group not served is one which may be termed "resource 
poor". These are people not of Indian blood, who live in 
very remote, isolated areas. Because of this they do not have 
any ready access to health care, but yet may live near one 
of the facilities of the IBS. Except in Alaska, by law, we 
are not permitted to treat people not considered to be part 62 
of the recipient population except in emergency instances. 
Finally, the need for provision of Services to Indians in 
urbanized areas, as discussed in item 3.c. is reiterated. 
5- a. Hov does the total federal, state and local effort in this 
area compare to past efforts in the United States? 
For years the major efforts to improve life for the Indians 
and Alaska Natives were centered in the IHS, PHS and BIA. 
There was little State or local effort on behalf of these 
people. Recent years have seen a dramatic change, however, 
many other Federal agencies have instituted programs which 
benefit the Indian and Alaskan people. In years past there 
has been little State or local effort on behalf of the Indian 
or Alaska Native people. However, with the passage of recent 
Federal legislation, and a growing social awareness on the 
part of the States and local municipalities, the Indian and 
Alaska Natives are receiving a greater share of benefits 
provided by these levels of government. Another factor is 
the growing awareness on the part of the Indians and Alaska 
Natives of their inherent rights as full citizens and their 
legal entitlements. With recent emphasis on comprehensive 
health planning and area-wide planning groups and councils, 
the Indians and Alaska Natives are gaining a greater voice 
in the determination of health programs in which they have a 
stake. 63 
b. Current efforts abroad? 
The Service has some input into reimbursable programs 
currently being conducted overseas. An example is the 
Participating Agency Service Agreement with the Agency 
for International Development to provide technical 
assistance to the Government of Liberia in developing 
their National Medical Center. IHS also administers 
a block of PL-480 money for medical research in several 
"soft-currency” countries. The Peace Corps has contracted 
with the IHS to provide training for volunteers now doing 
health-related work in Korea, Malawi and Afghanistan. II. 
BUDGET INFORMATION 64 
IT, Budget Information 
A. Report FY 1968-1970 Financial Data (Budget Authority and Outlays) 
FY 
FY 
FY 
1. Budget Authority 
1968 
1969 
1970 
Indian Health 
Services 
$ 84,835,000 
$ 94,282,000 $ 
99,581,000 
Indian Health 
Facilities 
16,848,000 
18,156,000 
20,000,000 
Total 
101,683,000 
112,438,000 
119,581,000 
2, Outlays 
Indian Health 
Services 
82,290,000 
89,279,000—/ 
96,800,000 
Indian Health 
Facilities 
12,050,000 
25,529,000i'/ 
23,544,000 
Total 
94,340,000 
114,808,000 
120,444,000 
B. Report history of Division submission, bureau recommendation, agency 
budget. Department budget, and Congressional action for each year. 
FY 
FY 
FY 
1. Bureau Recommendation 
1968 
1969 
1970 
Indian Health 
Services 
85,835,000 
106,324,000 
121,755,000 
Indian Health 
Facilities 
28,822,000 
72,775,000 
49,520,000 
Total 
114,657,000 
179,099,000 
171,275,000 
2, Agency Budget 
Indian Health 
Services 
84,835,000 
100,360,000 
101,916,000 
Indian Health 
Facilities 
28,822,000 
36,392,000 
25,800,000 
Total 
113,657,000 
136,752,000 
127,716,000 
3. Department Budget 
Indian Health 
Services 
84,781,000 
100,360,000 
101,916,000 
Indian Health 
Facilities 
32,083,000 
31,296,000 
22,600,000 
Total 
116,864,000 
131,656,000 
124,516,000 
1/ Expenditure levels set by the 
Bureau of the Budget, 
April 30, 1969 4. Congressional Action 
FY 
1968 
FY 
1969 
FY 
1970 
a. Budget Estimate to Congress 
Indian Health Services 
Indian Health Facil. 
$ 82,133,000 
22,211,000 
$ 95,907,000 
16,100,000 
$ 99,581,000 
20,000,000 
Total 
104,344,000 
112,007,000 
119,581,000 
b. House Allowance 
Indian Health Services 
Indian Health Facil. 
82,000,000 
14,733,000 
90.860.000 
16.100.000 
Total 
96,733,000 
106,960,000 
c. Senate Allowance 
Indian Health Services 
Indian Health Facil, 
82.645.000 
17.606.000 
90.860.000 
16.100.000 
Total 
100,251,000 
106,960,000 
d. Appropriation 
Indian Health Services 
Direct 
Indian Health Services 
Suppl.- — 
82,005,000 
2,857,000 
90,860,000 
3,490,000 
Total Indian Health 
Services 
84,862,000 
94,350,000 
Indian Health Facil. 
16,848,000 
18,156,000 
Total 
101,710,000 
112,506,000 
C. For FY 1970, indicate what part of the budget is uncontrollable, 
committed, or discretionary? 
The 1970 budget is ’’committed." III. 
LEGISLATIVE CHANGES (RECENT) 66 
III. LEGISLATIVE CHANGES (RECENT 
Report recent changes and how they affect items above. 
Item I,A.2, has been expanded to cover not only authorizing 
legislation for this program, but legislation affecting other 
agencies and departments as well, since many of these programs 
now have a direct bearing on the improvement of life for the 
Indians. The reader is referred to Section I.A.2. for a review 
of pertinent legislation, not only for the Indian Health Service, 
but for an overview of how other Federal programs are now impacting 
on the effort to provide a better life for Indians and Alaska 
Natives. Most of the legislation can be considered "recent" 
in the sense that most new laws and amendments to basic laws 
have been enacted within the last four years. IV. 
FORWARD PLAN 67 
IV. FORWARD PLAN 
A. National Goals, Needs and Program Objectives 
Show the total need (non-dollar) for the program to fully 
meet the national goals. State the desired program objectives 
that could be realistically achieved if dollar constraints were 
not considered. Indicate the non-dollar constraints, for example, 
knowledge, manpower, building time, etc., that would inhibit 
meeting the goal immediately. 
National goals and program objectives concerning Indian health 
are contained in three frames; the first pertaining to. the 
Federal Indian policy of this Administration, the second pertaining 
to health goals for the nation, and the third pertaining to Indian 
health itself. 
1. Federal Indian policy has been set forth as: i/ 
a. The special relationship between the Federal 
Government and the Indian people and the special 
responsibilities of the Federal Government to the 
Indian people will be acknowledged. 
b. The right of self-determination of the Indian 
people will be respected and their participation 
in planning their own destiny will actively be 
encouraged. 
1/ Taken from September 27, 1968 statement by President Nixon to 
the National Congress of American Indians at Omaha, Nebraska. 68 
c. The Economic Development of Indian Reservations 
will be encouraged and the training of the Indian 
people for meaningful employment on and off the 
reservation will be a high priority item. 
d. The Administration of Federal Programs affecting 
Indians will be carefully studied to provide maximum 
efficiency consistent with program continuity. 
e. Improvement of health services to the Indian people 
will be a high priority effort. 
2. National health goals are considered principally to he:i 
a. Improve the total health system of the Nation 
through experimentation, innovation and evaluation. 
b. Narrow the gap in services to the medically indigent 
and needy. 
c. Insure application of existing knowledge and reduce 
gaps in quality of services for all citizens. 
d. Reduce health hazards of the environment. 
e. Relate program support mechanisms, health services, and 
institutions to achieve community-determined systems 
of care. 
f. Constrain medical costs by developing resources and 
organizational and delivery capacities. 
1j Derived from background materials and reports for the DREW Health 
Task Force. 69 
g. Promote strength and flexibility in institutions. 
h. Provide for priorities: 
(1) Services that are family centered and comprehensive. 
(2) Expectant mothers and children. 
(5) The poor, near poor, and medically needy. 
(k) Core cities, migrants and the rural poor. 
5* The goal and objectives for a comprehensive Indian health 
program are as follows: 
Program Objectives 
The program objectives of a comprehensive program for Indian 
health can best be defined in terms of an expressed 
mission and goal. 
The mission is to assure a total health services system for 
meeting the health needs of American Indians and Alaska 
Natives. 
The goal is to raise the health level of the Indian and 
Alaska Native people to the highest possible level. 
The objectives for achieving this goal are to be accomplished 
emphasizing Indian and Alaska Native involvement and 
participation to the fullest extent with full utilization 
of available public and private resources. 70 
The objectives are: 
(a) To reduce the mortality and morbidity of Indians 
by providing expanded and improved preventive 
health services, treatment of disease and rehabilitative 
services. 
(b) To improve the physical environment. 
(c) To improve understanding among the Indians and 
Alaska Natives of health practices such as personal 
hygiene, nutrition and drugs and societal factors 
related to health such as housing and sanitation. 
h. A Comprehensive Health Services System for Indians and 
Alaska Natives 
a. Conceptual Framework 
A conceptual frame-work is set forth below in which a 
total health services system for meeting the health 
needs of American Indians and Alaska Natives can be 
planned, implemented, and evaluated with full participation 
by the Indian people themselves. 
The additional objective for the framework is that it 
provide for a comprehensive Indian health program to be 
planned, operated, evaluated, improved and coordinated 
with other systems with a focal point for responsibilities 
and authorities. By authorization and practice that 71 
focal point has been the Indian Health Service (iHS). 
It is planned that IHS will continue to have focal 
responsibility for delivering and coordinating the 
delivery of health services for Indians, coordinating 
with other resources and promoting Indian leadership 
and direction of comprehensive health services for 
Indians. 
b. Characteristics 
The characteristics of the framework have been designed 
so that: 
(1) It assures the carrying out of the cited guidelines 
for Federal Indian policy, particularly the right 
of Indian self-determination in regard to matters 
of health. 
(2) It provides for Indians the concern, attention, 
and services emanating from National health priorities. 
(3) It insures flexibility and options in order to most 
effectively achieve the Indian health goal and 
objectives. 
It provides a process which moves over a period of 
time toward the objective of Indian control and 
administration of the Indian health program. 
(5) it assures that actualization of the conceptual 
framework begins, returns, and continues at the smallest 
possible unit or Indian community in which services 
are provided. 72 
c. Explication of Conceptual Framework 
The framework embraces what may be considered the 
three basic components which are common to any form 
of management, namely: 
Planning 
Implementation 
Evaluation 
The additional component discussed below which is woven 
throughout each of these components and the overall 
management of a comprehensive Indian health program is 
Indian participation. Experience has shown that 
participation by the people in all program aspects is 
indispensable in the reduction of health or other social 
problems. Thus the Indian participation component is 
treated as a phase, step or task to both highlight it 
and to prevent its submergence under each of the other 
tasks. 
The framework is divided into six phases, steps, or 
tasks. Each task is numbered to facilitate the identification 
of the steps in the continuum in which they are not mutually 
exclusive. 73 
The Forward Plan which follows thus consists of the following 
tasks:i/ 
Task 
1.0 Indian Participation 
( 2.0 Identification of Health Problems and Needs 
Planning ( 
( 5-0 Identification and Selection of Resources 
Implementation h.O Delivery and Coordinating Delivery of 
Health Services 
( 5.0 Assurance of Quality and Quantity 
Evaluation ( 
( 6.0 Provision of Program Management 
5. Forward Plan and Objectives 
The following is a further explanation of the tasks or steps 
in the conceptual framework for a comprehensive Indian health 
program. At the same time this explanation along with the inclusion 
of issues and projects in the Appendix constitutes a Forward Plan. 
The described Forward Plan is presented as a realistic or high 
program level through 1975 and is based on an absence of dollar 
constraints. Accomplishment of the realistic plan will insure that 
certain basic objectives through 1975 are achieved. These basic 
objectives for this time period are: (l) to have improved 
significantly the quality and quantity of comprehensive personal 
health services, field health services, environmental services, 
and systems of health care delivery for Indians, and (2) to have 
increased Indian participation in new and existing health services 
in their communities. 
J_/ Based cn Report of the Task Force to Evaluate and Develop the Contract 
Medical Care Program of the Division of Indian Health May 17, 1968. 74 
Projects associated with the achievement of the high program 
level are briefly described in Appendix II. Budget and outputs 
for the high level are listed in Section IV-B. In Appendix I are 
listed a number of problems or issues in preliminary form, the 
resolution of which will help optimise the direction and effect of 
the program in years to come. Finding solutions to the problems 
listed in Appendix I is expected to provide new insights and 
opportunities and thereby enhance the ouality and effectiveness 
of the realistic program described in this section and in the 
projects in Appendix II. With one exception the projects in 
Appendix II are not basically dependent upon the resolution of 
issues. The exception is the project for Advanced Training of Sub- 
professional Health Staffs (also see Legislation Requirements 
Section IV-D). In several cases resolution of the issues will be 
dependent upon the proposed projects. 
In the event funds are limited to maintenance of essentially 1970 
program levels, an alternative or low program level is circumscribed 
by the low level outputs and budget in Section IV-B. This level 
will preclude accomplishment of the cited outputs and thwart the 
continuation of the movement toward emphasis on preventive services 
as well as retard resolution of the issues and problems cited in 
Appendix I. 75 
Finally, a second alternative or medium program and budget is 
included in Section IV-B. This level will permit maintenance 
of essentially 1970 program levels with the provision of additional 
thrust in nutrition and mental health and a small increase in 
facilities planning. The description of steps or tasks in the 
Forward Plan which begins on the following page is applicable 
to all three program and budget levels. The description of each 
task includes one or more subobjectives for that task by 1975 along 
with a brief resume of the status of the progress toward the 
subobjective(s). 76 
FORWARD PLAN 
FOR A 
COMPREHENSIVE INDIAN HEALTH PROGRAM 
Task 1.0 ASSURE INDIAN PARTICIPATION 
Background 
Indian participation is indispensable in a comprehensive 
health program for Indians as it is in any community health 
endeavor; it is also in keeping with the Federal Indian 
policy and National goals for health. 
Indian participation has been provided for in a formal way 
since the Indian Reorganization Act of 195*+. The most 
recently issued Indian Health Service statement on Indian 
participation is contained in the Annual Report to the 
First Americans. It states: 
"We consider the Federal Indian Health Program 
to be your program carried out in accordance 
with your wishes and requirements. The Indian 
Health Service is the instrument for providing 
services which are planned, conducted and 
evaluated with you as individuals and as organized 
tribal and community groups." 
Indian participation may be viewed as the lattice through 
which the whole program for Indian health operates. 
Subobjectives 
The subobjectives in Indian participation are: (l) to 
have at least one Tribal Health Committee and/or Board 
of Health related to each of the 87 IHS Service Units; 77 
(2) to have 100$ of the membership on each of the 8 IHS 
Area Advisory Committees and the Headquarters IHS Advisory 
Committee filled by Indians who are selected by the Indian 
people themselves. 
Status 
Indian participation is occurring in the development of 
plans operations and evaluation in each of the 87 ms Service 
Units, 
The following is the status in regard to Tribal Health Committees 
and Boards of Health; 
4 
No. of Inter- 
No, of Area 
No. of 
Reservation 
No. of 
Community 
No. of 
Tribal Health 
Advisory 
or Tribal Health 
Health 
Area 
Tribes 
Committees 
Boards 
Committees 
Committees 
Aberdeen 
kl 
7 
1 
1+1 
20 
Albuquerque 
2 6 
1 
0 
8 
0 
Anchorage 
‘ 5i/ 
5 
i 0 
< 16 
0 
Billings 
11 
1 
1 
11 
5 
Oklahoma City 
38 / 
9 
1 
58 
?6 
Phoenix 
Uj2/ 
5 
1 
1+5 
Portland 
51 
k 
0 
51 
5 
Tucson HPSC 
1 
0 
0 
1 
11 
Navajo 
1 
0 
1 
6 
95 
•mm 
1 11 
195 
52 
5 
195 
216 
1/ In the Anchorage Area, we are basing the tribal affiliations in the manner 
that the Alaska Natives regard their three groups, namely; Eskimos, Aleuts, 
and Indians. Tribal or band divisions are not used. 
2/ The large number of rancherias in California receive only P. L. 86-121 
sanitation facilities from the Indian Health Service and are not counted 
in this chart. 78 
In regard to Indian membership, the membership of 
Service Unit advisory groups is all Indian. The 
membership of the Area Advisory Committees is also all 
Indian. After July 1, 19&9* "the Advisory Committee on 
Indian Health will move from a minority to majority of 
the membership being Indians (6 out of 9 members). 79 
Task 2.0 IDENTIFY HEALTH PROBLEMS AND NEEDS 
Background 
A key step in developing a comprehensive Indian health 
services program is the definition of the health problems, 
health related problems, and felt needs of the Indian 
community. This task also requires establishing (1) a 
community profile, (2) utilization patterns, (3) unmet 
needs and constraints. 
Subobiectives 
The subobjectives in this task are (1) to define health 
problems and health status of each Indian community as 
specifically as it is defined at Area and National levels, 
and (2) to identify utilization patterns and establish unmet 
needs as noted above for each Service Unit and/or Area 
with respect to direct health services, contract health 
services, and alternate health services (see Task 3,0). 
Status 
In calendar year 1969, three significant actions were taken 
to impel progress in each of the subobjectives cited above. 
The first was the implementation of the recommendations of 
the Task Force to Evaluate and Develop the Contract Medical 80 
Care Program of the Division of Indian Health. The 
second was the issuance of guidelines for Service Unit 
Planning and Data Requirements developed in two workshops 
hy IHS personnel with Indian participation. The third was 
the conference called to consider long range goals for 
Indian health which had nearly Indian participants 
and an Indian co-chairman. 
As a result of these events, identification of problems and 
needs, and the planning, operation and evaluation which will 
follow are proceeding with Indian participation throughout. 
Efforts will be directed toward establishing better numerators 
and denominators of needs, e.g., population bases (1970 
Census) health status at local levels and specifics about 
health related conditions. Work is proceeding to have 
better data bases and capability to provide technical 
assistance when needed. 
An indication of the magnitude of the problems of morbidity and 
mortality of Indians is provided in Section I-A-6. 81 
Task 5.0 IDENTIFY AND SELECT RESOURCES 
Background 
This task is the heart of comprehensive planning with THS 
as the focal and coordinating point in the process. Critical 
to the process is the establishment of interagency resources 
planning groups so that agencies can work with each other and 
with tribes in developing comprehensive plans and in identifying 
resources. 
As discussed in Section I-B-2 the identification and selection 
of health resources applies to (l) direct services (or the 
Indian Health Service), (2) contract services (or services 
which the Indian Health Service contracts and pays for), and 
(5) alternate services (or services available to Indians 
but paid for by sources other than the Indian Health Service). 
Resources related to health must be identified and selected, 
e.g., sanitation, transportation and communication. 
Subobjective 
The subobjective in this area is to synthesize alternative 
health services systems (direct, contract, and alternate services) 
for each IHS service unit and select the optimal system 
including methods and means against established criteria which 
include individual needs and tribal desires as well as benefits 
and costs; similarly for resources such as sanitation, 
transportation and other health related resources. 82 
Status 
Directories of-'resources are being established. Also 
established are liaisons locally and at the Headquarters 
level to work closely with other agencies concerned with 
comprehensive planning, e.g.. Bureau of Indian Affairs and 
Economic Development Administration. 
The synthesis of alternative health care systems and 
selection of optimal systems will become a more deliberate 
and better documented process. Criteria for selecting the 
optimal system with needs of the individual as the prime 
consideration have been established. 
Additional emphasis will be placed upon transportation 
and communication linkages as discussed in the projects in 
Appendix II. 
Some of the task of identifying resources makes mandatory 
effective planning at the IHS Area and Headquarters levels 
Such support plans are being developed in conjunction with 
the Service Unit planning process. 83 
Task k.O DELIVER AND COORDINATE DELIVERY OF HEALTH SERVICES 
Background 
This task is the implementation or operational step. 
It is closely linked to the identification and selection 
of resources through the process of feedback from carrying 
out the subtask of setting priorities for provision of 
services. This is the programming of what is going to be 
done as compared with the planning of what should be done 
in Task 5*0. This step also includes providing effective 
education, developing understanding, achieving favorable 
attitudes, arriving at sound decisions and effecting 
appropriate actions by individuals, staff, organizations 
and communities. 
Programming implies splitting up into activities and it 
will be necessary to look at the program in several ways. 
Some of these ways are (l) in terms of health problems, 
(2) in terms of mode of delivery (e.g., inpatient), 
(5) in terms of provider (e.g., contract services), 
(U) by services (e.g., normal development or prevention), 
and (5) by facility (e.g., extended care). 84 
Subobjective 
The program subobjectives in delivery and coordinating 
the delivery of health services are expressed as outputs in 
Section IV By Program Requirements. Under all program levels 
the emphasis -will be on early prevention and treatment in an 
ambulatory setting with the addition of other means of 
providing bed care so as to tend to reduce the need for 
hospital beds. Some of the highlight objectives in the 
realistic plan are as follows; 
1971 1975 
Patient Days 9*+2,000 95^,000 
(Reduction in TB inpatient care) 
Outpatient Visits 1,110,000 1,350,000 
Field Medical Services 1,255*000 
Mental Health Teams 4- 8 
Sanitation Services 
Technical Assistance and 
Consultative Services to 
Families and Communities 118,000 155*000 
Status 
Program effectiveness is discussed in Section I-C and program 
accomplishments in I-A-3* 
The additional dimensions in the Forward Plan will emphasize 
provision of (l) entry points for the individual into the 
system, (2) system linkages, e.g., transportation, (3) referrral 
and follow-through, (1+) outreach and communication 85 
e.g., the Community Health Representative program, 
(h) orientation and informing of staff and Indian 
people, (6) evaluation of performance against plans. 86 
Task 5.0 ASSURE QUALITY AND QUANTITY 
Background 
This task of the program is intended to assure high 
quality of services in Task U.O and a sufficient quantity 
of quality resources in Task 5.0 through (l) development 
and application of standards, (2) research and development, 
and (5) training and personnel development. 
These activities apply in a similar respect as do the 
delivery activities in Task U.O that is to direct, contract, 
and alternate services and resources. Similar cooperation 
is explicit in a quality assurance program, research and 
development activities and in training and manpower programs. 
Subobjectives 
The subobjectives are: 
(l) Quality assurance program in which nationally 
accepted standards are applied to all IMS direct 
delivery and contract health care services. 
(2) Training and research and development levels 
which will tend to put into the health care system 
as much as the Indian health resource needs tend to 
take out of the system, and 
(5) A career development program which will result in 
the following; 
An increasing number of Indians filling professional 
and managerial positions; 87 
• All key positions filled by persons who 
have a broad perspective of health program 
management; 
• An understudy or Indian counterpart in development 
for all key positions; 
# A range of career options for individual growth 
and development; 
* Flexibility of movement within and without the 
Indian Health Service. 
Status 
Application of standards is already basic policy. Additional 
stress will be given to implementation of the program 
and follow up on results especially in reshaping the 
configuration of resources in Task 5.0. 
Discussion of research and development efforts by the IHS 
Health Program Systems Center is provided in Section I-B-7. 
Expansion of those efforts is discussed in the Projects in 
Appendix II. 
The present and future directions of training efforts are 
also discussed in Section I-B-7* Appendix II and in 
Legislative Requirements Section IV-D. 
The state of career development of Indians in IHS is discussed 
in I-A-7- 88 
Task 6.0 PROVIDE PROGRAM MANAGEMENT 
Background 
This task could also be called administrative support 
because it supports all of the other steps which precede 
it in the cycle. It is concerned with efficiency, effectiveness 
and economy. 
This task also applies to direct, contract and alternate 
services and resources. It will require extensive coordination 
with other programs and compatability with State and local 
agencies in the area of planning and operational information. 
Subobjectives 
The subobjective in this aspect is the provision of data 
systems, fiscal and procedural controls and administrative 
analyses through which quality and quantity of health care 
services can be provided while containing the rise in costs 
of those services. 
Status 
During the past few years substantial efforts have been made 
to improve the data base for Indian Health. Additional thrust 
will come with the forthcoming acquisition of computer 
capability for data processing. A new system of fiscal 
and procedural controls is under trial with respect to the 
contract health services system. 89 
Special emphasis will be carried out with regard to 
manpower deployment, administrative audits and cost 
containment activities. High Level 
B. Program Requirement 
1, Show for each year (FY 1971*1973) the estimated program output which would be necessary 
to achieve the realistic objectives set forth in A, above and the percentage of the need 
met by this output. 
Fiscal Year 
71 
11 
22. 
7k 
11 
Direct Care 
Patient Days 
General Medical & Surgical 
650,000 
652,000 
656,000 
656,000 
656,000 
Tuberculosis 
38,200 
36,000 
3^,600 
32,800 
31,000 
Outpatient Visits 
1,110,000 
1,170,000 
1,230,000 
1,290,000 
1,350,000 
Contract Health Care 
Patient Days 
25^,000 
252,000 
2k8,000 
21+7,000 
21+7,000 
Outpatient Visits 
177,000 
200,000 
223,000 
21+6,000 
269,000 
Public Health Nursing 
PHN Services - Clinic 
117,800 
136,000 
158,000 
182,000 
212,000 
PHN Services School 
89,500 
10*+,000 
121,000 
11+1,000 
l61+,000 
PHN Services Office Visits 
65,000 
76,000 
88,000 
102,000 
118,000 
PHN Services Home Visits 
151,000 
175,000 
203,000 
236,000 
27^,000 
PHN Group Teaching Patient 
Services 
2,81+0 
3,300 
3,830 
**,330 
5,020 
90 
July 30, 1969 High Level(Cont' 
Fiscal Year 
IV-B-1 continued 
71 
72 
11 
jk 
rii 
Dental Services 
New outputs are shown under project No. 5 listed below. 
Sanitation Services 
Technical Assistance and 
Consultative Services 
to Families 
61,800 
71,500 
79,000 
80,000 
81,200 
Technical Assistance and 
Consultative Services 
To Communities 
56,200 
65,000 
71,800 
72,800 
73,800 
Field Medical Services 
Visits to Physicians 
Health Centers 
38^,000 
i+80,000 
60^,000 
670,000 
775,000 
School Health Centers 
51,000 
59,000 
7^,000 
82,000 
95,000 
Other Clinics 
3*»7,000 
352,000 
363,000 
37^,000 
385,000 
Health Education 
Outputs are shown in the listing of the alternate or low level which follows. Also see 
project No, 2. 
Listed are the output measures associated with the listing of proposed projects according to 
priority. These outputs are not included in the other output measures listed above, 
1. Provide Training for Increased Numbers of Community Health Representatives and Native 
Health Aides 
Output 
71 
72 
22. 
7h 
11 
Community Health Representa- 
tives (CHRs) trained 
300 
300 
300 
316 
- 
Alaska Native Health Aides 
(AHNAs) trained 
* 
* 
115 
*-* 
** 
* 185 Aides in 3 year training program begun 
in FY 1970 
July 30, 1969 
** 115 Aides in 3 year training 
program begun 
in FY 1973 
91 IV-B-1 continued High Level (Cont'd'1 
2. Mental Health 
Output 
71 
72 
Fiscal Year 
73 
11 
11 
Cumulative number of mental 
health teams at Area offices 
k 
6 
8 
8 
8 
Number of community mental 
health workers trained per 
year 
100 
100 
100 
100 
100 
3. Nutrition 
Output 
71 
72 
73 
7^ 
75 
Percent of target population 
receiving adequate nutrition 
and dietetic information, 
and services while in health 
facilities 
35 
6o 
75 
90 
U. Community and Housing Sanitation 
Output: See separate output for facility construction. 
5. A total Dental Program for American Indians, Eskimos and Aleuts 
Output 
71 
72 
73 
7*+ 
75 
Percent of population on 
maintenance level of dental 
care 
29 
31 
33 
36 
38 
92 
July 30, 1969 IV-B-1 continued High Level (Cont'd) 
6. Program to Reduce Morbidity and the Prevalence of Crippling Sequelae from Middle Ear 
Disease 
Output 
71 
72 
Fiscal Year 
73 
lit 
75 
Expected incidence in the 
population with this 
expanded program 
10$ 
8* 
6* 
** 
3$ 
T. Expand the Accident Prevention and Injury Control Prototype Program 
Output 
71 
72 
73 
71 
75 
Reduction 
in 
Deaths 
90 
100 
110 
120 
135 
Reduction 
in 
hospital discharges 
1,500 
1,650 
1,815 
1,995 
2,190 
Reduction 
in 
outpatient visits 
11,200 
12,250 
13,500 
11,900 
16,300 
8. Special Training Requirements 
- Health Program Management Training for Indians 
- Advanced Training for Sub-professional Health Staff 
Output 
71 
72 
73 
lh 
75 
' 
Number of Health Management 
Trainees trained 
1,000 
1,000 
1,000 
1,000 
1,000 
Number of sub-professionals 
given advanced training 
100 
100 
100 
100 
100 
93 
July 30, 1969 IV-B-1 continued High Level (Cont'd^ 
9. Initiate Indian Household Population Surveys and the Issuance of Social Security 
Numbers to Indians and Alaska Natives 
Output 
71 
72 
Fiscal Year 
73 
7^ 
75 
Percent of Indian population 
surveyed as to health,socio- 
economic and environmental 
data 
n 
6 
9 
11 
13 
Percent of Indian population 
having social security numbers 
55 
70 
85 
100 
10. Laboratory Program 
Output 
71 
72 
73 
7^ 
75 
Cumulative number of central 
Area laboratories established 
6 
8 
8 
8 
3 
11. Expand and Improve School Health Centers Services 
Output 
71 
72 
73 
7^ 
75 
Number of new health centers 
constructed and operating 
2 
2 
2 
1 
1 
12. Provide Extended Care Capability 
Output 
71 
12 
73 
It 
11 
Number of beds provided in 
extended care facilities 
200 
h00 
6oo 
Boo 
1,000 
94 
July 30, 1969 IV-B-1 continued High Level (Cont'd') 
13. Participate in the Development of a Public Transportation System for Indians 
Output 
71 
72 
Fiscal Year 
n 
7U 
Number of Reservations with 
Public transportation 
assistance 
3 
5 
5 
5 
5 
Development of Model Communications Systems 
Output 
71 
72 
n 
Hi 
11 
Percent of facilities and 
vehicles adequately linked 
12 
28 
62 
80 
15. Proposal for Regional Rehabilitation Program for Navajo Area 
Output 
n 
72 
n 
]h 
n 
Percent of patients treated 
30 
33 
36 
ho 
kk 
l6. New Type of Health Care Delivery System 
Output 
H- 
72 
n 
Tit 
is 
Number of prototype and/or 
demonstration projects 
undertaken 
2 
2 
2 
2 
2 
95 
July 30, 1969 IV-B-1 continued High Level (Cont'd'* 
17. Extension of Health Care Services to Selected California Communities. 
Output 
2! 
n 
Fiscal Year 
n 
ih. 
n 
Percent of California Indians 
provided adequate health 
service (non-urban) 
85 
85 
85 
85 
85 
96 
July 30, 1969 97 
IV. B. 1 - Cont'd 
INDIAN HEALTH FACILITIES 
Program Output 
High Level 
Output Measures 
1970 
President1s 
Budget 
1971 
Fiscal Year 
1972 1973 1974 
1975 
New and replacement hospitals 
3 
2 
2 
2 
2 
Extended care facilities,,.. 
6 
6 
6 
8 
8 
Modernization and repair 
of hospitals. 
. 3 
8 
20 
12 
12 
11 
New and replacement 
health centers 
3 
3 
5 
5 
5 
3 
New and replacement 
health stations 
4 
13 
23 
11 
19 
12 
Modernization and repairing 
of clinics 
. 1 
5 
8 
1 
2 
2 
IHS participation in 
community facilities..,,,. 
2 
1 
1 
1 
1 
Number of homes receiving 
running water and adequate 
waste disposal 
8,670 
10,450 
9,900 
9,200 
8,700 
8,700 
Additional homes benefitting 
from other sanitation 
facility improvements 
1,700 
2,300 
2,400 
2,500 
2,550 
2,500 
Number of units of quarters 
constructed 
. 6 
300 
680 
680 
680 
680 
July 29 
, 1969 B. Program Requirements (continued) Medium Level 
2. Layout for the period (FY 1971-1979) a medium level program 
NOTE; For FY 1971 the medium level outputs for activities are the same as the low level 
which follows with the addition of the mental health and nutrition project outputs from the 
high which precedes this. For facilities several planning projects are provided above the 
low level outputs. (See separate table). For FY 1972 and beyond the medium level outputs 
for activities are the same as the high level with some changes in facility outputs by 
year. (See separate table) 
FISCAL YEAR 
11 
72 
75 
jh 
15 
Direct Care 
Patient Days 
General Medical and Surgical 
Tuberculosis 
655,000 
58,200 
650,000 
58,200 
652,000 
56,000 
656,000 
5i+,6oo 
656,000 
52,800 
Outpatient Visits 
1,085,000 
1,110,000 
1,170,000 1, 
0 
0 
0 
•s 
0 
rOv 
OJ 
1,290,000 
Contract Health Care 
Patient Days 
2^6,010 
25^,000 
252,000 
21+8,000 
21+7,000 
Outpatient Visits 
167,000 
177,000 
200,000 
225,000 
21+6,000 
Public Health Nursing 
PHN Services - Clinic 
100,000 
117,800 
156,000 
158,000 
182,000 
PHN Services School 
77, 1+00 
89,500 
10l+, 000 
121,000 
11+1,000 
PHN Services Office Visits 
56,300 
65,000 
76,000 
88,000 
102,000 
PHN Services Home Visits 
150,000 
151,000 
175,000 
205,000 
256,000 
PHN Group Teaching Patient 
Services 
2,^50 
2,8I+0 
5,500 
5,850 
u,530 
July 50, 1969 
98 IV-B-2 (continued) (Medium Level - Cont'd) FISCAL YEAR 
71 
72 
73 
lit 
75 
Dental Services 
Percent of Population on 
maintenance level of 
dental care 
29 
29 
51 
35 
56 
Sanitation Services 
Technical Assistance and 
Consultative Services to 
Families 
U6,Uoo 
6l,800 
71,500 
79,000 
80,000 
Technical Assistance and 
Consultative Services to 
Communities 
k2,200 
56, 200 
65,000 
71,800 
72,800 
Field Medical Services 
Visits to Physicians 
Health Centers 
560,000 
38^,000 
hQo,000 
60k,000 
670,000 
School Health Centers 
000 
51,000 
59,000 
7^,000 
82,000 
Other Clinics 
3^7,000 
3^7,000 
352,000 
363,000 
37^,000 
Health Education 
Clinic Services (individuals) 
k2,000 
U2,000 
1+3,500 
1+3,500 
kh, 500 
Home Health Services (Visits) 
22,000 
22,000 
22,500 
22,500 
22,500 
Community Services (Groups) 
652 
652 
675 
675 
690 
Service Unit Staff Coverage 
52$ 
52/0 
55$ 
55$ 
55$ 
99 
July 30, 1969 IV-B-2 (continued) (Medium Level - Cont'd) 
FISCAL YEAR 
71 
72 
73 
lit 
75 
Mental Health 
Output 
Cumulative number of mental 
health teams at Area Offices 
Number of community mental 
health workers trained per 
h 
6 
8 
8 
8 
year 
Nutrition 
100 
100 
100 
100 
100 
Output 
Percent of target population 
receiving adequate nutrition 
and dietetic information, and 
services while in health 
facilities 
35 
6o 
75 
90 
100 101 
IV. B. 2 - Cont'd 
INDIAN HEALTH FACILITIES 
Program Output 
Medium Level 
Output Measures 
1970 
President1s 
Budget 
1971 
Fiscal Year 
1972 1973 
1974 
1975 
New and replacement hospitals 
1 
2 
2 
2 
3 
Extended care facilities.,.. 
0 
6 
6 
8 
8 
Modernization and repair 
of hospitals 
. 3 
5 
22 
12 
12 
11 
New and replacement 
health centers., 
, ' 3 
0 
4 
7 
6 
3 
New and replacement 
health stations 
4 
2 
29 
11 
19 
12 
Modernization and repairing 
of clinics 
. 1 
4 
9 
1 
2 
2 
IHS participation in 
community facilities 
0 
2 
1 
1 
1 
Number of homes receiving 
running water and adequate 
waste disposal 
8,670 
8,300 
9,900 
9,200 
8,700 
8,700 
Additional homes benefitting 
from other sanitation 
facility improvements 
1,700 
2,300 
2,400 
2,500 
2,550 
2,500 
Number of units of quarters 
constructed 
. 6 
25 
680 
680 
680 
680 
July 29, 1969 B. Program Requirements (continued) LOW LEVEL 
5. Layout for the period (FY 1971-1-975) an alternative program level which would maintain 
program output (or coverage) at a constant FY 1970 level by taking into account growth 
in population and other specified relevant factors. Indicate what revisions in program 
objectives would be necessary and the percentage of the total need that would be met if 
this alternative were chosen. 
Direct Care 
Patient Days 
General Medical and Surgical 
Tuberculosis 
71 
655,000 
58,200 
72 
655,000 
56,000 
FISCAL YEAR 
11 
655,000 
5U,600 
655,000 
52,800 
11 
655,000 
51,000 
Outpatient Visits 
1,085,000 
1,115,000 
1, 
, 160,000 
1,172,000 
Contract Health Care 
Patient Days 
2^6,010 
21+3,390 
259, M+o 
238,31+5 
236,155 
Outpatient Visits 
167,000 
167,000 
167,000 
167,000 
167,000 
Public Health Nursing 
PHN Services - Clinic 
100,000 
101,000 
101,000 
101,100 
101,200 
PHN Services - School 
77,^00 
77,1+50 
77,1+50 
77,500 
77,500 
PHN Services - Office Visits 
56,300 
56,350 
56,350 
56,550 
56, i+00 
PHN Services - Home visits 
150,000 
150,000 
151,000 
151,000 
151,000 
PHN Group Teaching Patient 
Services 
2, U50 
2,1+50 
2, 500 
2,500 
2,500 
102 
April 30, 1969 IV-B-3 (continued) LOW LEVEL (Cont'd) 
Ii 
72 
FISCAL YEAR 
75 
lit 
15 
Dental Services 
Direct 
Number of Individuals 
Provided Preventive 
Procedures 
100,000 
100,100 
10k,000 
10l+, ooo 
10l+,000 
Number of Individuals 
Provided Dental Care 
159,ooo 
ikl,ooo 
ll+l, 000 
ii+3,000 
11+5,000 
Number of Dentral Treatments 
Provided 
61+5,ooo 
61+5,000 
61+8, ooo 
650,000 
650,000 
Contract 
Number of Individuals 
Provided Preventive 
Procedures 
9,500 
9,500 
9,700 
9,700 
9,900 
Number of Individuals 
Provided Dental Care 
15,000 
15,000 
15,200 
15,200 
15,1+00 
Number of Dental Treatments 
Provided 
76,100 
77,000 
79,ooo 
81,ooo 
81,ooo 
Sanitation Services 
Technical Assistance and 
Consultative Services 
to Families 
1+6,1+00 
1+6,800 
1+7,000 
1*7,500 
1*7,500 
Technical Assistance and 
Consultative Services 
to Communities 
1+2,200 
1+2,1+00 
1+2,600 
1+2,800 
1+2,800 
103 
April 30, 1969 IV-B-3 (continued) LOW LEVEL (Coni'd) 
71 
72 
FISCAL YEAR 
75 
7^ 
75 
■ 
1 ' 
Field Medical Services 
Visits to Physicians 
Health Centers 
560,000 
1+00,000 
1+20,000 
1+30,000 
1+1+0,000 
School Health Centers 
1+8,000 
1+8,000 
1+8,000 
1+8,000 
1+8,000 
Other Clinics 
31+7,000 
55i,ioo 
562,1+00 
575,200 
385,000 
Health Education 
Clinic Services (individuals) 
1+2,000 
1+2,000 
1*5,500 
1*3,500 
1+1+, 500 
Home Health Services (Visits) 
22,000 
22,000 
22,500 
22,500 
22,500 
Community Services (Groups) 
652 
652 
675 
675 
690 
Service Unit Staff Coverage 
52/„ 
5 s$ 
55$ 
55 % 
55$ 
104 
April 30, 1969 105 
IV. B. 3 - Cont’d 
INDIAN HEALTH FACILITIES 
Program Output 
Low Level 
Output Measures 
1970 
President1s 
Budget 
1971 
Fiscal Year 
1972 1973 
1974 
1975 
New and replacement hospitals 
1 
0 
0 
0 
0 
Extended care facilities 
0 
0 
0 
0 
0 
Modernization and repair 
of hospitals 
3 
6 
0 
2 
0 
0 
New and replacement 
health centers 
3 
0 
1 
0 
0 
1 
New and replacement 
health stations... 
4 
2 
0 
0 
4 
4 
Modernization and repairing 
of clinics 
1 
4 
0 
0 
0 
2 
IMS participation in 
community facilities 
0 
0 
0 
0 
0 
Number of homes receiving 
running water and adequate 
waste disposal 
8,670 
8,300 
8,700 
8,700 
8,700 
8,700 
Additional homes bene fitting 
from other sanitation 
facility improvements 
1,700 
2,300 
2,400 
2,500 
2,550 
2,500 
Number of units of quarters 
constructed 
6 
25 
21 
0 
59 
27 
July 2 9, 1969 IV. C. BUDGET PROJECTION 
106-a 
HIGH LEVEL 
INDIAN HEALTH SERVICES 
Budget Projection - 1971 through 1975 
High Level 
(In Thousands of Dollars) 
Appropriation 
Structure 
1970 
President1s 
Budget 
1971 
Mandatory 
Increases 
Program 
Total 
1971 
Total 
Program 
Patient Medical Care: 
$73,241 
$11,006 
$17,462 
$28,468 
$101,709 
Direct 
54,152 
8,537 
15,263 
23,800 
77,952 
Indirect (CMC) 
19,089 
2,469 
2,199 
4,668 
23,757 
Field Health Svcs, 
25,661 
5,038 
11,895 
16,933 
42,594 
Sanitation 
4,205 
851 
2,048 
2,, 899 
7,104 
Dental 
3,257 
664 
981 
1,645 
4,902 
P.H, Nursing 
2,940 
335 
932 
1,267 
4,207 
Health Education 
1,216 
150 
1,316 
1,466 
2,682 
Fid. Med. Svcs. 
14,043 
3,038 
6,618 
9,656 
23,699 
Menominee 
350 
(350) 
- 
(350) 
-0- 
Administration 
um 
232 
122 
354 
2,281 
Total 
101,179 
15,926 
29,479 
45,405 
146,584 
Less Reimbursements 
1,598 
1,598 
Total Direct 
99,581 
15,926 
29,479 
45,405 
144,986 HIGH LEVEL (Cont'd) 
106-b 
INDIAN HEALTH SERVICES 
Budget Projection - 1967 through 1975 
High Level 
(In Thousands of Dollars) 
1972 
Increases 
1972 
Total 
1973 
Increases 
1973 
Total 
Mandatory 
Program 
Total 
Program 
Mandatory 
Program 
Total 
Program 
$6,381 
$10,601 
$16,982 
$118,691 
$3,976 
$9,870 
$13,846 
$132,537 
4,237 
8,679 
12,916 
90,868 
1,480 
7,947 
9,427 
100,295 
2,144 
1,922 
4,066 
27,823 
2,496 
1,923 
4,419 
32,242 
2,739 
6,461 
9,200 
51,794 
2,366 
7*195 
9,561 
61,355 
95 
547 
642 
7,746 
92 
444 
536 
8,282 
56 
428 
484 
5,386 
61 
483 
544 
5,930 
57 
596 
653 
4,860 
57 
606 
663 
5,523 
45 
403 
448 
3,130 
45 
313 
358 
3,488 
2,486 
4,487 
6,973 
30,672 
2,111 
5,349 
7,460 
38,132 
- 
- 
- 
- 
- 
- 
- 
- 
40 
— 
40 
2,321 
40 
40 
2,361 
9,160 
17,062 
26,222 
172,806 
6,382 
17,065 
23,447 
196,253 
— 
1,598 
_ 
1,598 
9,160 
17,062 
26,222 
171,208 
6,382 
17,065 
23,447 
194,655 HIGH LEVEL (Cont’d) 
106-c 
INDIAN HEALTH SERVICES 
Budget Projection - 1971 through 1975 
High Level 
(In Thousands of Dollars) 
1974 
Increases 
1974 
Total 
1975 
Increases 
1975 
Total 
Mandatory 
Program 
Total 
Program 
Mandatory 
Program 
Total 
Program 
$5,977 
$9,834 
$15,811 
$148,348 
$4,534 
$10,065 
$14,599 
$162,947 
3,162 
8,343 
11,505 
111,800 
1,362 
8,532 
9,894 
121,694 
2,815 
1,491 
4,306 
36,548 
3,172 
1,533 
4,705 
41,253 
2,073 
5,890 
7,963 
69,318 
4,805 
7,509 
76,827 
95 
84 
179 
8,461 
103 
60 
163 
8,624 
74 
495 
569 
6,499 
91 
478 
569 
7,068 
77 
619 
696 
6,219 
97 
593 
6 90 
6,909 
50 
293 
343 
3,831 
55 
293 
348 
4,179 
1,777 
4,399 
6,176 
44,308 
2,358 
3,381 
5,739 
50,047 
- 
- 
- 
- 
- 
- 
- 
- 
40 
40 
2,401 
40 
40 
2,441 
8,090 
15,724 
23,814 
220,067 
7,278 
14,870 
22,148 
242,215 
— 
1,598 
_ 
1,598 
8,090 
15,724 
23,814 
218,469 
7,278 
14,870 
22,148 
240,617 107 
IV. C, Budget Projetion 
INDIAN HEALTH FACILITIES - NOA* 
5-Year Plan-In Thousands 
High Level 
1970 
President's 
Budget 
1971 
Fiscal Year 
1972 1973 
1974 
1975 
Hospitals 
New and replacement 
13,419 
5,392 
18,120 
7,054 
20,301 
Modernization and repair 
157 
1,919 
10,680 
8,084 
5,589 
1,020 
Extended care facilities 
8,000 
8,000 
8,000 
8,000 
8,000 
Outpatient care facilities 
1,763 
3,258 
7,350 
4,683 
5,744 
3,008 
Community facilities 
1,790 
750 
750 
750 
750 
Sanitation facilities.,0.. 
17,950 
22,500 
23,000 
23,000 
23,400 
24,800 
Personnel quarters 
130 
11,166 
17,299 
24,892 
17,680 
17,380 
TOTAL............ 
20,000 
62,052 
72,471 
87,529 
68,217 
75,259 
* New obligational authority 
July 29, 1969 MEDIUM LEVEL 
108-a 
INDIAN HEALTH SERVICES 
Budget Projection - 1971 through 1975 
Medium Level 
(in Thousands of Dollars) 
1970 
1971 
Appropriation 
President * s 
1971 Increases 
Total 
Structure 
Budget 
Mandatory 
Program 
Total 
Program 
Patient Medical Care: 
$73.21*1 
$11,006 
$508 
$11,511* 
$81*, 755 
Direct 
5l*,152 
8,537 
508 
9,01*5 
63,197 
Indirect (CMC) 
19,089 
2,1*69 
- 
2,1*69 
21,558 
Field Health Svcs. 
H166I 
5.038 
6.1*53 
32.nl* 
Sanitation 
1*,205 
851 
— 
851 
5,056 
Dental 
3,257 
66*+ 
- 
66*+ 
3,921 
P.H. Nursing 
2,9*+0 
335 
- 
335 
3,275 
Health Education 
1,216 
150 
- 
150 
1,366 
Fid, Med. Svcs. 
l*+,0*+3 
3,038 
1,1*15 
it, 1*53 
18,*+96 
Menominee 
350 
(350) 
- 
(350) 
- 
Administration 
1,927 
232 
— 
232 
2.159 
Total 
101,179 
15,926 
1,923 
17,81*9 
119,028 
Less Reimbursements 
1.598 
1,598 
Total Direct 
99,581 
15,926 
1,923 
17,81*9 
117,1*30 MEDIUM LEVEL (Cont'd) 
INDIAN HEALTH SERVICES 
Budget Projection - 1971 through 1975 
Medium Level 
(In Thousands of Dollars) 
108-b 
.... 1972. 
Increases 
1972 
Total 
1973 Increases 
1973 
Total 
Mandatory 
Program 
Total 
Program 
Mandatory 
Program 
Total 
Program 
$3.75** 
$17.133 
$22,887 
$107,642 
$3.27*t 
$10,575 
$13.8**9 
*lgl.**91 
3,998 
l**,93*t 
18,932 
82,129 
1,130 
8,653 
9,783 
91,912 
1,756 
2,199 
3,955 
25,513 
2,144 
1,922 
4,066 
29,579 
1,258 
12*521 
13.889 
46,003 
g.g39 
8 .**51 
8,690 
3**.693 
65 
2,048 
2,113 
7,169 
92 
5**7 
639 
7,308 
hi 
1,331 
1,372 
5,293 
53 
428 
481 
5,77*t 
45 
932 
977 
i+, 252 
57 
596 
653 
**,905 
25 
1,316 
1,3**1 
2,707 
45 
403 
448 
3,155 
1,182 
6,904 
8,086 
26,582 
1,992 
**,**77 
6,469 
33,051 
40 
122 
162 
2,321 
33 
..... 33 
2,35** 
7,152 
29,786 
36,938 
155,966 
5,5**6 
17,026 
/ 
22,572 
178,538 
— 
«• 
. 1.598 
— 
— 
1.598 
7,152 
29,786 
36,938 
154,368 
5,5**6 
17,026 
22,572 
176,940 MEDIUM LEVEL (Cont'd) 
108-c 
INDIAN HEALTH SERVICES 
Budget Projection - 1971 through 1975 
Medium Level 
(in Thousands of Dollars) 
Increases 
1971* 
Total 
1975 Increases 
1975 
Total 
Mandatory 
Program 
Total 
Program 
Mandatory 
Program 
Total 
Program 
$5,708 
$9.817 $15.525 
$137.016 
$1*.177 
$9.831* 
$ll*,011 $151,027 
3,212 
7,89!* 
11,106 
103,018 
1,362 
8,31*3 
9,705 
112,723 
2,1*96 
1,923 
M19 
33,998 
2,815 
1,1*91 
1*,306 
38,301* 
1.931* 
6.967 
8.901 
63.591* 
g.l*35 
5.890 
8.325 
71.919 
95 
l+uu 
539 
3,31*7 
95 
8U 
179 
8,526 
6h 
U83 
5**7 
6,321 
7*+ 
1*95 
569 
6,890 
67 
606 
673 
5,578 
77 
619 
696 
6,271* 
50 
313 
363 
3,518 
50 
293 
31*3 
3,861 
1,658 
5,121 
6.779 
39,830 
2,139 
1*,399 
6,538 
MS,368 
Uo 
UO 
2.391* 
ho 
Uo 
2.1*31* 
7,682 
l6,78U 
2k,U66 
203,00U 
6,652 
15,72U 
22,376 
225,380 
— 
_ 
1.598 
•• 
1,598 
7,682 
l6,78U 
2k,k66 
201,U06 
6,652 
15,721* 
22,376 
223,782 109 
IV. C. Budget Projection 
INDIAN HEALTH FACILITIES - NO A* 
5-Year Plan-In Thousands 
Medium Level 
1970 
President’s 
Fiscal Year 
Budget 
1971 
1972 
1973 
1974 
1975 
Hospitals 
New and replacement 
Modernization and repair 
Extended care facilities 
157 
6,055 
1,454 
6,741 
10,879 
8,000 
6,015 
8,084 
8,000 
19,027 
5,589 
8,000 
23,096 
1,020 
8,000 
Outpatient care facilities 
1,763 
594 
6,722 
6,675 
6,144 
3,008 
Community facilities 
1,790 
750 
750 
750 
Sanitation facilities 
17,950 
18,500 
23,000 
23,000 
23,400 
24,800 
Personnel quarters 
130 
1,175 
20,212 
17,862 
25,040 
17,380 
TOTAL 
20,000 
27,778 
77,344 
70,386 
87,950 
78,054 
* New obligational authority 
July 2 9, 196 9 LOW LEVEL 
110-a 
INDIAN HEALTH SERVICES 
Budget Projection - 1971 through 1975 
Low Level 
(In Thousands of Dollars) 
1970 
Appropriation 
President's 
1971 
Total 
Structure 
Budget 
Increase 
1971 Program 
Patient Medical Care 
$73,241 
$11,006 
$84,247 
Direct 
54,152 
8,537 
62,689 
Indirect 
19,089 
2,469 
21,558 
Field Health Services: 
25,661 
5,038 
30,699 
Sanitation 
4, 205 
851 
5,056 
Dental 
3, 257 
664 
3,921 
P.H. Nursing 
2,940 
335 
3,275 
Health Education 
1, 216 
150 
1,366 
Field Medical Svcs. 
14,043 
3,038 
17,081 
Menominee 
350 
(350) 
— 
Administration 
1,927 
232 
2,159 
Total 
101,179 
15,926 
117,105 
Less Reimbursements 
1,598 
— M 
1,598 
TOTAL DIRECT 
99,581 
15,926 
115,507 LOW LEVEL (Cont'd) 
110-b 
INDIAN HEALTH SERVICES 
Budget Projection - 1971 through 1975 
Low Level 
(In Thousands of Dollars) 
1972 
Total 
1973 
Total 
Increases 
1972 Program 
Increases 
1973 Program 
$3,267 
$87,514 
$3,415 
$90,929 
1,511 
64,200 
1,408 
65,608 
1,756 
23,314 
2,007 
25,321 
1, 297 
31,996 
550 
32,546 
95 
5,151 
62 
5,213 
131 
4,052 
38 
4,090 
90 
3,365 
35 
3,400 
55 
1,421 
20 
1,441 
926 
18,007 
395 
18,402 
40 
2,199 
33 
2,232 
4,604 
121,709 
3,998 
125,707 
1,598 
M 
1,598 
4,604 
120,111 
3,998 
124,109 LOW LEVEL (Cont'd) 
110-c 
INDIAN HEALTH SERVICES 
Budget Projection - 1971 through 1975 
Low Level 
(In Thousands of Dollars) 
1974 
Total 
1975 
Total 
Increases 
1974 Program 
Increases 
1975 Program 
$3,718 
$94,647 
$4,065 
$98,712 
1,511 
67,119 
1,635 
68,754 
2, 207 
27,528 
2,430 
29,958 
594 
33,140 
937 
34,077 
65 
5, 278 
73 
5,351 
41 
4,131 
128 
4, 259 
45 
3,445 
55 
3,500 
25 
1,466 
30 
1,496 
418 
18,820 
651 
19,471 
40 
2, 272 
47 
2,319 
4,352 
130,059 
5,049 
135,108 
1,598 
- . 
1,598 
4,352 
128,461 
5,049 
133,510 IV. C. Budget Projection 
INDIAN HEALTH FACILITIES - NO A* 
5-Year Plan-In Thousands 
Low Level 
1970 
President's 
Fiscal Year 
Budget 
1971 
1972 
1973 
1974 
1975 
Hospitals 
New and replacement 
Modernization and repair 
Extended care facilities 
157 
6,055 
1,035 
2,345 
Outpatient care facilities 
1,763 
594 
646 
862 
1,798 
Community facilities 
Sanitation facilities 
17,950 
18,500 
20,600 
22,000 
23,400 
24,800 
Personnel quarters 
130 
1,175 
1,554 
1,538 
702 
TOTAL 
20,000 
27,359 
22,800 
24,345 
25,800 
27,300 
* New obligational authority 
July 2 9, 196 9 BUDGET PROJECTION - SUMMARY (in Thousands) 
Fiscal 
Year 
Indian 
Health . 
Services ±1 
Indian 
Health 
Facilities 
Total 
High Level 
President * s 
1970 Budget 
$101,179 
$20,000 
$121,179 
1971 
1*46,58*4 
62,052 
208,636 
1977 
172,606 
72,1*71 
245,277 
1973 
196,253 
87,529 
283,782 
197*4 
220,067 
68,217 
288,28*4- 
1975 
2*42,215 
75,259 
317,474 
Medium Level 
President * s 
1970 Budget 
101,179 
20,000 
121,179 
1971 
119,028 
27,778 
l*+6,806 
1972 
155,966 
77,344 
233,310 
1973 
178,538 
70,386 
2*48,92*+ 
19711 
203,00*4 
87,950 
290,954 
1975 
225,380 
78,054 
303,434 
Low Level 
• 
President1s 
1970 Budget 
101,179 
20,000 
121,179 
1071 
117,105 
27,359 
1*4*4, *46*4 
1972 
121,709 
22,800 
1*4*4,509 
1273 
125,707 
24,345 
150,052 
197*4 
130,059 
25,800 
155,859 
1975 
135,108 
27,300 
162, *408 
— All years include $1,598,000 reimbursements 113 
D. Legislation Requirements 
For the preferred plan of Part C indicate 
1. Extension of existing legislation needed 
The sense of Congress should he determined in regard to 
extension of Public Law 89-£>55 which authorizes special 
assistance to the Menominee Indian people at a level of 
$350,000 and which expires at the end of FY 1970. 
2. Extension needed with amendments (summarize) 
None 
3. New legislation needed (summarize) 
See list which follows. 
k. Administrative actions needed (specify) 
None 
SUMMARY OF NEEDED LEGISLATION 
PROPOSAL I 
Authority to permit the transfer, with the consent of the Indian tribes 
served, of facilities presently used, occupied or built by the Indian 
Health Service for health purposes to Indian tribes directly and to permit 
the detail of Indian Health Service employees to tribes for the conduct of 
health programs under the general direction of the tribe. 
The Indian Health Service has been working closely with tribes and Indian 
boards of health to encourage their participation in the conduct of an 
Indian Health program. In some instances it may be desirable to transfer 
Indian Health facilities to the tribe and to detail necessary personnel 
to permit the tribes to conduct a health program under their own direction 
By this procedure there will be increased participation of the Indian 
people in the health program, the development of the Indian people, and 
would provide for a program relevant to the needs of the Indian people. 114 
In order to accomplish this, authority is needed to transfer health 
facilities directly to the Indian tribes and to purchase health services 
from the tribe thereafter. 
The present "Partnership for Health" legislation permits detailing of 
Federal employees to State governments but authority is lacking to detail 
Federal employees to tribal organizations. We would, therefore, desire 
authority to detail Federal employees to tribal organizations not only 
for the operation of facilities as cited above but for other purposes as 
may be appropriate. 
It is intended that the transfer of facilities and any detail of personnel 
will be accomplished with the consent of the Indian tribes served by the 
facility or by the detail of personnel. This proposal would not, in any 
way, erode the responsibility of the Secretary for the conservation of the 
health of the American Indians. 
PROPOSAL II 
Authority to permit utilization of remote Indian Health facilities, with 
the consent of the Indian tribes served by the facilities, as community 
hospitals to permit utilization of such facilities by non-Indians and by 
private physicians. The health needs of Indian people will have priority 
over Federal employees and non-Indians for services at these remote facilities 
This proposal will facilitate community-wide health planning and permit a 
more realistic approach to the health programs of a community. It will 
tend to bring together non-Indians and Indians and assure full utilization 
of facilities in these remote areas. Legislation (S. 2kkl) has been 
introduced in the present Congress to accomplish this particular objective. 115 
PROPOSAL III 
Authority to make grants to Indian tribal organizations to conduct 
training programs and demonstration projects for health related activities 
such as alcohol control. Community Health Representatives, etc. 
This authority would give the Indian Health Service considerable flexibility 
in training and providing needed health services to the Indian people. 
The primary advantage of the program would be to provide additional 
alternatives to improve the quality and extend the range of health 
services to Indians. 
PROPOSAL IV 
Authority to contract with private health resources, with the consent 
of the Indian people served, on a pre-payment basis for services to 
Indian people served by the Indian Health Service. 
Presently, authority to contract on a pre-payment basis for health 
services with local private health resources, is not available to the Indian 
Health Service. This authority will make options available to the Indian 
people for the provision of health services either through direct services 
or contract services by the Indian Health Service and through private 
sources arranged by the tribe with the local private health resources. 
This authority would permit a more flexible and more comprehensive 
service to the Indian people and has the added advantage of permitting the 
Indian people to participate directly in the selection of the type of 
services they would prefer. 
This authority would not, in any way, erode the responsibilities of the 
Public Health Service for the conservation of the health of the Indians 
as provided under P. L. 83-568. 116 
PROPOSAL V 
Exceptions to Government Employees' Training Act of 1958. 
Nearly G(yj0 of the staff of the Indian Health Service is of 
Indian descent. One of our major thrusts is the greater 
involvement of Indians and Alaska Native people in planning, 
operating and evaluating their own health program. A vital 
preparatory step toward the Indian1s assumption of responsibility 
for his own health services is learning to plan and manage 
health programs. Removal of the hindrances invoked by 
section Ul06(a), title 5 of the U. S. Code will permit the 
Indian Health Service to eliminate the existing capability gaps. 
Accordingly, it is recommended that the restrictions imposed in 
section (l), (2) and (3) of title 5? U. S. Code be 
waived for Indian and Alaska Native employees of the Indian 
Health Service. In general these restrictions prohibit training 
for degree purposes and training is limited to improvements 
of skills already acquired. 
PROPOSAL VI 
Leasing of Personnel Quarters for IHS Employees. 
The proposal is to authorize the Indian Health Service to lease 
on a long-term basis personnel quarters from private owners and 
contractors for rental to Indian Health Service employees. 
This program would enable Indian tribal organizations to utilize their 
resources to carry out quarters construction and maintenance and would 
contribute vitally to the desirous milieu of a self-sustaining community APPENDIX I 
Issues APPENDIX I 
Issue s 
A. BACKGROUND 
As discussed in the 1971-1975 Program Report and Plan for Indian 
Health, the health status of Indians lags far behind that of the 
general population, in spite of considerable progress in this 
regard during the past 15 years. Forming a part of the root causes 
of the lag, and a crucial threat to continued and future progress, 
are a number of questions and problems. Many of these questions 
and problems relate to Indian ethnicity and self determination; 
to the application of professional and administrative technologies 
in Indian settings; and to the historical and legal thrust of 
national goals relative to the Indian people. 
A truly efficient and effective national effort directed to the 
well-being of the Indians will be possible to the extent that there 
is available the critically needed knowledge and understanding of 
these questions and problems so as to facilitate capacities for both 
strategic and tactical program planning, and for optimal operational 
and evaluative activities. 
Development of the required knowledge and understanding and solution 
of the unresolved questions and problems will require extensive and 
systematic effort. Because a "list” of detailed questions and 
problems is probably interminable, it will be necessary first to 2 
describe the questions and problems more precisely and to determine 
on the basis of valid criteria, a priority of hierarchy of problems 
for analysis as well as determining a hierarchy of opportunities 
for improvement. Next should come a more detailed analysis of the 
problems and opportunities to determine a hierarchy or priority 
for the synthesis of solutions and approaches. 
In the following paragraph are listed a number of areas of identified 
concern out of which can arise a clearer definition of problems and 
opportunities. The listing is not totally inclusive but is 
illustrative of questions and problems which have sufficient import 
and breath so as to form a basis for identifiable issues in the 
field of Indian affairs and Indian health. The items listed are 
not posed as questions or specific statements of issues; rather it is 
from these bases the true issues, albeit more detailed as a rule, 
can be derived. Thus it is proposed that the listed areas of concern 
be considered as "proto-issues" or a first statement pending their 
definition as true issues for exploration in the form of issue papers 
B. PHOTO-ISSUES 
1. Mission and goals for a total national effort to improve 
Indian health. 
2. Service population: the impact of the validity and reliability 
of denominators on health planning, operations, and evaluation. 
5. Provision of services for urban and other non-reservation groups. 3 
*4. Mechanisms to establish, define or otherwise clarify Indian 
authority and/or influence in all phases of program management, 
e.g., health hoards, contract with and grants to tribes for 
service. 
5. Mechanisms to coordinate interagency planning, delivery, and 
evaluation systems for a national effort aimed at improving the 
health and health-related statuses of Indians. 
6. The roles and relationships of intergovernmental jurisdictions 
in closing gaps in health services for Indians. 
7- The role of Indian Health Service facilities in areas where no 
facilities exist within reasonable distances to serve non-Indians, 
and/or where these facilities are or have a potential for being 
considered as part of coordinated, interagency health systems 
and the population they serve, e.g., Regional Medical Programs 
and efforts under Section of the PHS Act. 
8. Criteria for priority attacks on Indian health problems and for 
priority determination and quality control of health services. 
9. Manpower for improved health of Indians. 
-- Innovation: new types of manpower 
-- Restrictions and constraints 
-- Indians in health careers; health career ladders 
10. Development, testing, demonstration, and application of health 
systems, methods, and techniques for improved health of Indians. 
11. The role of grants and the ascription of grant authorities in an 
integrated national effort to improve Indian health. APPENDIX II 
Listing of Proposed Projects 
According to Priority APPENDIX II 
Listing of Proposed Projects According to Priority 
Project 
No. 
Title 
Page 
No. 
1. Provide Training for Increased Numbers of Community 
Health Representatives and Native Health Aides.... „. 1 
2. Mental Health 5 
3. Nutrition 5 
4. Community and Housing Sanitation . 8 
5. A Total Dental Program for American Indians, Eskimos 
and Aleuts „ .... 9 
6. Program to Reduce Morbidity and the Prevalence of 
Crippling Sequelae from Middle Ear Disease 15 
7. Expand the Accident Prevention and Injury Control 
Prototype Program . l4 
8. Special Training Requirements 15 
- Health Program Management Training for Indians and 
Alaska Natives 
- Advanced Training of Sub-Professional Health Staffs 
9. Initiate Indian-Household-Population Surveys and the 
Issuance of Social Security Numbers to Indians and Alaska 
Natives. l6 
10. Laboratory Program IT 
11. Expand and Improve School Health Centers Services 19 
12. Provide Extended Care Capability. 21 
13. Participate in the Development of a Public Transportation 
System for Indians..... 22 
14. Development of Model Communications Systems 25 
15. Proposal for Regional Rehabilitation Program for 
Navajo Area. 24 
16. New Type of Health Care Delivery System •••••• 25 
17. Extension of Health Care Services to Selected California 
Communities, 26 1 
PROJECT NO. 1 
Provide Training for Increased Numbers of Community Health 
Representatives and Native Health Aides 
The Indian Health Service, in providing a comprehensive health 
program for American Indians and Alaska Natives, has found 
community health representatives and Alaska native health 
aides to be an effective means of meeting the health needs of 
the population being served. The need is significant in all 
areas and is especially critical in Alaska, because of the 
nature of the problems (particularly isolation) and the 
difficulties in recruiting trained professionals to serve in 
isolated and depressed areas. 
The function of the trained community health representative 
is to serve as a member of the health team serving the 
community, to effectively speak for the community and to 
secure community support for health programs. In this 
connection these representatives participate by (1) making 
people aware of their health conditions and the availability 
of health services; (2) assisting families in doing things 
for themselves to improve and maintain their health; 
(3) conducting surveys and accumulating vital data; (4) inter- 
preting to the families the environmental conditions that need 
attention for improving health and participating in planned 
programs; (5) referring individuals to professional health 
personnel and following up on these referrals to insure that 
the individuals are following prescribed instructions and 
keeping scheduled appointments; and (6) educating and advising 
communities and individuals on non-professional aspects of all 
phases of the health program. 
The function of the Alaska Native Health Aide is substantially 
the same as that of the CHR, however, the extreme isolation 
factor in Alaska requires additional training to prepare the 
aide to provide a wide range of medical services under 
professional supervision received via short wave radio or 
telephone. 
Early experience with the program has demonstrated that the 
utilization of community health representatives and Alaska 
native health aides has resulted in more direct involvement for 
the Indian and Native leaders in providing for their own health 
needs and further extending health services. 2 
PROJECT NO. 1 - (continued) 
It is proposed that training be provided at the IHS Training 
Center and elsewhere to a total of 1,500 Indians in the 
Continental United States and 300 Alaska Natives in Alaska by 
1975. These trained auxiliaries will be used on a full or 
part-time basis and, in the 24 reservation States, will be 
administratively employed by the tribe with salaries and 
supporting costs funded by the Indian Health Service under 
contract with the tribes. Through the training and utilization 
of the Indian people as community health representatives the 
IHS service capability is extended and a continuing liaison is 
established between the IHS and the Indian community. Community 
Health Representatives can assist in the planning process at 
the local level as well as provide a communication linkage 
with regard to the effectiveness of program implementation. 
Costs 
To provide for a total of 1,500 CHR's and 300 Alaska Native 
Health Aides, it is proposed that training and employment be 
provided to an additional 1,216 CHR's; 300 each year, 1971 
through 1973, and 316 in 1974; and, an additional 115 Alaska 
Native Health Aides. The increased cumulative cost of this 
program follows: 
Fiscal Year 
1971 
1972 
1973 
1974 
1975 
$1,974,000 
$4,539,000 
$7,644,000 
$10,070,000 
$11,655,000 
April 30, 1969 Project No. 2 
3 
MENTAL HEALTH 
The effects of poverty, cultural class, geographic isolation, unemploy- 
ment, lack of education, degradation of the role of the father in the 
family, and an adverse physical environment all combine to develop in 
the reservation Indian a frustration and sense of hoplessness against 
which he feels he must lash out as best he knows how. The result of 
this are seen in the form of excessive use of alcohol, suicide, violence, 
disintegration of the family, and child neglect and abuse. This vicious 
cycle is perpetuated in the school system where the child must stay 
in what he feels to be a hostile environment, where his native language 
is not only not spoken but actually outlawed, and where the school is 
unable to provide an adequate parental substitute. 
Alternative methods of meeting the mental health problems arising from 
this situation are as follows: 
1. Traditional psychiatric care of the mentally ill through increased 
use of the private and non-Federal Governmental sector of psychiatric 
medicine. This has the disadvantage of high cost, lack of preventive 
services, and overburdening of the private and non-Federal Govern- 
mental sectors. 
2. Mental health teams of professional workers (psychiatrists, mental 
health nurses, psychiatric social workers, psychologists, etc.) 
at each major Service Unit. This has the disadvantage of an un- 
warranted drain on the national resources for these scarce personnel. 
3. Professional mental health teams at each of eight Area Offices 
giving overall direction and consultation to professional and 
non-professionals at the Service Unit level. These persons as the 
Service Unit level would consist of health professionals (in general, 
physicians, but also nurses and social workers) with short-term 
training in mental health; indigenous community mental health 
workers; and the regular professional staff of the Public Health 
Service Hospitals and Health Centers with additional training in 
the field of mental health through a series of annual Area-wide 
mental health workshops. 
This latter alternative is recommended and a budget is proposed. 
Descriptive background literature describing the mental health 
problems among Indians is available. 4 
Fiscal Year 
1971 
1972 
1973 
1974 
1975 
1. Mental Health Team in all Areas 
(4 more teams needed) 
200,000 
300,000 
400,000 
400,000 
400,000 
2. Mental Health Program Officer 
Major Service Units 
240,000 
480,000 
720,000 
960,000 
1,200,000 
12/year x 5 = 60 total 
@ 20,000/man year 
3. Community Mental Health Workers 
(Total of 500) 
Number Trained: 
(100) 
(100) 
(100) 
(100) 
(100) 
Training at Indian Health Training Center 
28,000 
28,000 
28,000 
28,000 
28,000 
Travel to and from Indian Health Training 
Center 
20,000 
20,000 
20,000 
20,000 
20,000 
Salaries GS-3 + Travel on job 
620,000 
1,240,000 
1,860,000 2 
,480,000 
3,100,000 
4. Mental Health Workshops in each 
area 
50,000 
50,000 
50,000 
50,000 
50,000 
TOTALS 
1,158,000 
2,118,000 
3,078,000 3 
,938,000 
4,798,000 
April 30, 196 9 
Project No» 2 (Cont'd) 
estimated Costs for Alternative 3 5 
Proiect No. 3 
NUTRITION 
NUTRITION PROBLEM 
For a number of years poor nutritional status has been identified as a 
major health problem among the Indian and Alaska Native population. Mild 
and moderately severe nutritional deficiences are relatively common with 
infants, preschool children and women in the childbearing years (13-44) 
particularly vulnerable to malnutrition. Malnutrition occurs per se and 
as a contributing or complicating factor in a wide variety of other health 
problems and illness such as infectious disease, retarded physical growth, 
high infant iiorbidity and mortality, maternal morbidity, nutritional anemia, 
significant overweight or underweight, and chronic disease. 
The major problem faced by the Indian and Alaska Native population is lack 
of food and economic resources to provide adequate diets and lack of know- 
ledge of the relationship of food to health which motivates the best use of 
the resources that are available. 
PROPOSED ACTIONS 
In order to elevate the nutritional health of the Indian and Alaska Native 
and to maintain a safe level of nutritional status, there must be available 
food resources, adequate both in quantity and nutritional quality, and a 
concurrent and continuing nutrition education program. 
Methods of increasing and improving available food resources for the Indian 
and Alaska Native might include: 
1) Making the USDA administered Commodity Foods Program and the Supplemental 
Food Program for Low Income Groups Vulnerable to Malnutrition available to 
a larger proportion of families; increasing the available variety and 
quantity of these foods; liberalizing eligibility requirements; providing 
foods in appropriate sized containers to meet the limitations imposed by 
lack of refrigeration, home storage facilities, and family utilization of 
these food items; providing sufficient delivery and distribution points 
and adequate warehousing in each state; and assuring assistance to 
families in transporting commodities from distribution centers to their 
home s. 
2) Extending the Food Stamp Program to more families; simplifying and 
liberalizing eligibility and participation policies and procedures and 
increasing the quantity of stamps provided per dollar for eligible famil- 
ies . 
3) Providing additional food stamps and additional commodities of high 
nutritive value to meet medically indicated nutritional needs of individ- 
uals, including those with diagnosed malnutrition and nutrition related 
disease. Project No. 3 (Cont'd) 
6 
4) Removing present legal restrictions on simultaneous distribution of food 
stamps and regular commodities in same location. 
5) Establishing an Interdepartmental Committee including representatives 
from PHEW (IHS). USDA, and the Department of Interior, as well as tribal 
representatives, to resolve the issues involving food assistance programs. 
Ail these food assistance programs can produce a significant improvement in 
dietary intakes of recipients if eligibility and logistical problems can be 
resolved. Even at best none of the programs is designed to provide a com- 
pletely adequate diet for recipients and must be supplemented by other eco- 
nomic and food resources. 
Methods of providing nutrition education concurrently with food resources 
might include: 
1) Providing professional public health nutritionists and dietitians in 
all IHS Area Offices and Service Units. 
2) Providing an optimum mix of professional nutrition and dietetic staff 
and indigenous workers by training Indian and Alaska Native nutrition 
aides and IHS hospital food service workers to extend the skills of the 
professional nutritionist and dietitian in improving the nutritional 
knowledge and health of families and individuals. 
Education, together with adequate food resources, it the most significant and 
essential tool in combating nutrition porblems and is a major focus of pro- 
gram efforts of the limited professional nutrition and dietetics staff present- 
ly employed by IHS. Nutrition and dietetic service are reaching less than 
25% of Indians and Alaska Natives served by IHS. In order to provide needed 
nutrition and dietetic services for all Indians and Alaska Natives as discussed 
in this document,a minimum of 52 public health nutritionists and 48 dietitians 
will be required. This represents an increase of 40 nutritionists and 23 
dietitians over currently funded positions. By the end of FY 1975, 96 Indian 
and Alaska Native nutrition aides and 96 food service workers will be trained. 
(30 food service supervisors trained in Fy 69 & 70). An additional 90 food 
service workers are needed for IHS hospitals. 
RECOMMENDATIONS: 
It is recommended: 
1) That proposals (1) through (5) above for improving and increasing food 
resources available to the Indian and Alaska Native be pursued by IHS. 
2) That proposal (2) on this page for providing nutrition education services 
which suggests a combination of professional nutrition staff and trained 
indigenous workers for meeting the nutrition education needs of the Indian 
and Alaska Native be adopted. 
A proposed budget follows. Project No. 3- (Cont'd) 
7 
INCREASED CUMULATIVE COSTS AND STAFFING, 1971-1975 
1971 
1972 
1973 
1974 
1975 
Food Service Training 
$ 29,000 
$ 71,000 
$ 87,000 
$ 87,000 
$ 87,000 
Nutrition Aide Training 
100,000 
160,000 
210,000 
210,000 
210,000 
New Staff 
Nutritionists 
157,000 
288,000 
419,000 
472,000 
525,000 
Dietitians 
115,000 
179,000 
243,000 
270,000 
297.000 
Food Service Workers 
364,000 
437.000 
510,000 
583,000 
656,000 
TOTAL 
765,000 
1,135,000 
1,469,000 
1,623,000 
1,775,000 
Staffing 
Food Service Training 
Staff 
3 
4 
4 
4 
4 
Trainees 
16 
20 
20 
20 
20 
Nutrition Aide Training 
Staff 
3 
4 
4 
4 
4 
Trainees 
8 
16 
24 
24 
24 
Nutritionists 
12 
22 
32 
36 
40 
Dietitians 
9 
14 
19 
21 
23 
Food Service Workers 
50 
60 
70 
80 
90 8 
Project No, 4 
COMMUNITY AND HOUSING SANITATION 
The Sanitation Facilities Construction Act of nine years ago has 
made it possible to provide running water and an adequate means 
of waste disposal for 54 percent of the estimated total of 73,500 
Indian families coming within the jurisdiction of the Indian health 
program. An additional 15,000 families have benefitted from a 
number of other types of sanitation improvements. 
Coordination has been and will be carried out with other agencies 
having home building authority and with Tribal groups sponsoring 
home building (Bureau of Indian Affairs, the Department of Housing 
and Urban Development, the Office of Economic Opportunity and various 
Indian housing authorities). 
The optimum objective is provision and proper utilization of safe 
water and adequate waste disposal facilities for all Indians and 
Alaska Native families. 
By continuing its ongoing comprehensive program and adding extra 
emphasis to the special problems such as education, the Indian Health 
Service is confident of continued movement toward its goal of raising 
the health status of Indians and Alaska Natives to the highest possible 
level. 
Key to the emphasis plan for community and housing sanitation is 
Indian appreciation of sanitation measures and facilities in addition 
to their contributions of labor, materials and funds. The program 
will continue to consist of two parts namely: 
1. Providing proper water supply for Indian homes 
and communities; safe facilities for the disposal 
of all sewage through an expanddd Sanitation 
Facilities Construction Program. 
2. Encouragement of community effort in planning, 
implementation and maintaining sanitation 
improvements and practices. 
Costs 
FY 
FY 
FY 
FY 
FY 
1971 
1972 
1973 
1974 
1975 
$22,500,000 
$23,000,000 
$23,000,000 
$23,400,000 
$24,800,000 
July 29, 1969 9 
Project No, 5 
A TOTAL DENTAL PROGRAM FOR 
AMERICAN INDIANS. ESKIMOS AND ALEUTS 
With current resources the Indian Health Service is only able to 
provide about 24 percent of the dental care needed by the eligible 
American Indians, Eskimos and Aleuts. Most of this care is provided 
to children. A total program is planned which will place S3 percent 
of the total population on a maintenance level of care in ten years. 
The program is planned so that there will be a minimal and short 
lived reduction in the use of the resources when the maintenance 
level is reached. The following five year cost increase estimates 
consider the availability of clinical facilities, staff quarters, 
manpower, and a realistic effective demand for dental services: 
FY 
1971 - $1,209,000 
1972 - 529,000 
1973 - 601,000 
1974 - 662,000 
1975 - 500,000 
These figures include all the projects that are attached. 
Although two projects show no costs, they are included so as to 
present a complete picture of this total dental emphasis plan. 
April 30, 1969 10 
Project No. 5 (Cont’d) 
Increase in Number of Dental Interns to be 
Trained In the Indian Health Service 
This program, while providing additional dental care to the Indian 
population, will also provide the inexperienced young dentist an 
experience with a children's dental program. It also provides training 
in efficient dental practice, preventive dentistry, public health, and 
community dentistry as well as improve his clinical skills. The Indian 
Health Service Internships help to fulfill the obligation of the Public 
Health Service to the health profession-at-large to provide opportunities 
for hospital training for the graduate dentists. There is a nationwide 
shortage of such opportunities. The estimated additional cost per year 
are: 
FY 
iS7i - $110,000 
1972 - 14,000 
1973 - 140,000 
1974 - 0 
1975 - 0 
Research Project on Expanded Functions for 
Dental Assistants 
The greatest problem facing dentistry Is the growing shortage of 
dentists. This project is designed to explore a method for increasing 
the capacity of the dentist to provide services. It is attempting 
to determine the level of quality that can be expected when the dental 
assistants perform certain procedures which have been traditionally 
in the realm of the dentist. It will also study the efficiency of 
various combinations of assistants to dentists when the assistants 
perform the expanded functions. The increased cost per year to carry 
out this project are: 
FY 
1971 - $60,000 
1972 - 35,000 
1973 - 0 (end of project) Project No. 5 (Cont'd) 
11 
Provide Training for Indian Deaf 1 
Assistants for the Indian Health Program 
and for the Profession-at-Large 
The greatest problem facing dentistry today is the growing shortage 
of professional manpower. This project proposes to help increase 
the supply of dental assistants and thus improve the oral health 
level of the American people by providing more dental care for 
them. It has been shown that a dental assistant will improve the 
productivity of a dentist by about one-third. A second benefit from 
the project will be an improvement in the economic base of the Indian 
people, 
FY 
1971 - $19,000 
1972 - 19,000 
1973 - 0 
1974 - 0 
1975 - 0 
Provide Training to Indian Health 
and Private Dentists in Efficient 
Practice Management 
The Dental Services Branch of the Indian Health Service proposes to 
train private dentists as well as its own dentists and their assistants 
for one week in efficient dental practice management. This training 
has been shown to increase the productivity of Indian Health Service 
dentists by an average of 13 percent. This increase is retained for 
at least pne year after training. It has been determined that the 
cost of training is made up in the form of increased services after 
3 months after the training. About 30 additional teams could be 
trained in the Indian Health Service's facilities in 1971. The 
Increased costs are as follows: 
F. Y. 1971 - $30,000 
This cost will be maintained for the five-year period. 12 
Project No. _5 (Cont'd) 
Dental Resource Criteria and 
Program Requirements for the 
Indian Health Service 
The Indian Health Service dental program has developed a resource 
criteria and program requirement document. It represents a systems 
approach to dental programming. Basically its purpose is to 
provide a rational approach for determining the dental resources 
needed at particular locations. It will be used by persons associated 
with the planning, staffing, financing, and approving of requests for 
additional resources. It could also be useful to the development of 
other public dental programs such as the proposed nationwide children’s 
Dental Program, 
There is no additional cost associated with this project. 
Computerized Dental Date Svstem 
The Indian Health Service initiated an automated data system in 
fiscal year 1966 which provides comprehensive epidemiological measures 
of the oral health level of all Indians and Alaska Natives. It 
also provides information concerning services provided which will 
improve the dental health level. The information from this system 
allows dental administrators to evaluate programs based on accurate, 
pertinent, and current statistics. The ultimate benefit is an increase 
in quality of care for the patient. The system can serve as a model 
for use in other public dental programs. 
There is no additional cost associated with this project. £jrojep.t. 6. 
13 
PROGRAM TO REDUCE MORBIDITY AND THE PREVALENCE 
OF CRIPPLING SEQUELAE FROM MIDDLE EAR DISEASE 
Otitis media is one of the most prevalent infectious diseases 
among Indian people and Alaska natives. The reporting of new cases 
has continued to increase steadily since 1961 when this disease was 
first recorded by all Indian Health Service facilities. It has been 
the first of second leading notifiable disease since that time. In 
1967 there was a total of 30?211 cases of otitis media reported by the 
Indian Health Service with a rate of 7?800 per 100,000 population. In 
the same year 1,667 discharges from Indian and contract hospitals were 
for middle ear disease; this represented 17,177 hospital days. In 
addition, contract outpatient services were provided for 2,330 cases 
of otitis media in 1967. It has replaced tuberculosis as the major 
health problem among Indians in all Areas, inflicting serious and 
often permanent damage to those persons who contract this disease. 
The principal program impact to date has been in the treatment 
of active cases and to some extent in the provision of restorative surgery. 
Case finding, screening, definitive long term care, optimum restorative 
procedures, and rehabilitation are other aspects of a complete ear pro- 
gram that have not been adequately carried out. Staff need training in 
the proper diagnosis and treatment of chronic middle ear disease and 
appropriate consultants and equipment are required to support the program. 
Finally the Indian people themselves have not fully recognized the 
draining ear as an illness with potential serious consequences that 
needs medical care, nor do they have an understanding of the importance 
of treating an acute earache or minor cold which frequently results in 
a draining ear. Preventive health education is an underlying requirement 
in the resolution of this problem. 
The Indian Health Service proposes a comprehensive program plan 
for the resolution of these severe otologic health problems. The 
approach is threefold: (l) preventive measures which attack environ- 
mental, social, cultural and educational factors which contribute to 
the incidence of otitis media, (2) case finding and treatment of acute 
otitis media with emphasis on controlling the infection in the under 
two age group, and (3) treatment of chronic otitis media and screening 
to correct complications and their sequelae and to institute appropriate 
rehabilitative measures. 
FY 
FY 
FY FY 
FY 
Costs; 1971 
1972 
1978 1974 
1975 
$1,850,000 
$1,550,000 
$1,1*50,000 $1,450,000 
$1,450,000 
April 30, 1969 14 
Project No. 7 
EXPAND THE ACCIDENT PREVENTION AND INJURY CONTROL PROTOTYPE PROGRAM 
The death rate per 100,000 population indicates that accidents are 
presently the leading cause of death among the Indian population. 
Projections based on trends indicate that the rate of increase in 
the death rate due to accidents will continue to rise through 
FY 75 unless a preventive program is effectively established to 
deminish that increase. 
Accidents are due to environmental inadequacies and a lack of 
educational preparation for the people to cope with environmental 
problems. Personnel and resources are needed to plan and conduct 
studies for identifying these factors which contribute to accidents 
among the Indian population and for programming activities to 
reduce the high rates. 
Specialized staff is needed to assist Indian leaders and groups 
to plan and carry out health educational and promotional activities 
geared to accident prevention and to involve other agencies and 
organizations that can contribute. Through this proposal eight 
health education and seven program analyst positions will be 
funded to coordinate the accident prevention activity. Regular 
Service Unit staff will incorporate accident and injury control 
programs through education and demonstration activities into 
existing programs such as maternal and child health, environmental 
sanitation and patient education. The program will utilize 
community health aides on a full-time basis in the treatment of 
injuries and provision of other assistance. 
Fiscal Year 
Cost 
1971 
1972 
1973 1974 
1975 
$273,000 
$303,000 
$333,000 $363,000 
$393,000 
April 30,1969 Project No. 8 
15 
SPECIAL TRAINING REQUIREMENTS 
Health Program Management Training for Indians & Alaska Natives 
A vital preparatory step toward the Indian’s assumption of responsibility 
for his own health services is learning how to plan and manage health 
programs. A number of special seminars and training courses have been 
held for Indians and Alaska Natives and a need for such training will 
continue to exist for several years. A minimum of one thousand people 
per year should be trained in the techniques of health program management 
in programs conducted for a period of not Less than two weeks in duration 
at the training facilities of the Indian Health Service. 
Advanced Training of sub-professional health staffs 
Advanced training of sub-professional health staffs leading to bachelor’s 
or undergraduate degrees in several categories is needed to upgrade the 
levels and competencies of health staffs (many of whom are employees 
of Indian descent). A minimum of a hundred such employees should be 
scheduled for training each year for the next five years. This will 
provide a total cadre of 500 such employees or approximately ten per 
Indian Health Service hospital facility. 
Costs 
Fiscal Year 
m... 
1972 
1973 
1974 
1975 
Health Prog. Mgt. 
Trng. of Ind. & 
Alaska Natives 720,000 
720,000 
720,000 
720,000 
720,000 
Undergraduate 
training of 
sub-profes- 
sionals 900,000 
900,000 
900,000 
900,000 
900,000 
1,620,000 
1,620,000 
1,620,000 1 
,620,000 
1,620,000 
April 30, 1969 Proiect No, 9 
16 
INITIATE INDIAN-HOUSEHOLD-POPULATION SURVEYS AND THE ISSUANCE OF 
SOCIAL SECURITY NUMBERS TO INDIANS AND ALASKA NATIVES 
It is proposed that a series of household surveys be carried out to 
provide health, socio-economic and environmental data on the Indian 
population served by the Indian Health Service. As part of the 
household surveys but not limited to them will be the development 
of means to identify all Indians through the ilse of Social Security 
numbers. 
Advantages of Proposal 
Data would become available concerning disability, acute and chronic 
conditions, utilization of services, socio-economic and demographic 
factors in relation to health status, housing characteristics, mobility, 
patterns of maternal health care, etc. Health data would be available 
on a population base rather than a discharge or visit base. The use 
of Social Security numbers will provide a unique identification number 
which will provide a rapid means of identification of data for individuals 
as services are provided throughout the health care system. The use of 
the number in machine rather than manual systems will facilitate the dupli- 
cation of repetitive identifying information on health care forms used in 
providing services. 
Fiscal Year 
Cost: 1971 
1972 
1973 1974 
1975 
$150,000 
$ 125,000 $100,000 $75,000 
$75,000 
April 30, 196 9 17 
Project No. 10 
LABORATORY PROGRAM 
In an attempt to improve the quality of medical care delivered to 
Indian people, the Indian Health Service has started a program of 
systematic upgrading of the clinical laboratories of the Indian 
hospitals. It is realized that this is going to be a long and 
costly process but one which is essential to assure high-quality 
medical care for the people. 
As a first step, the Indian Health Service has asked the National 
Communicable Disease Center, Laboratory Program, to make an 
intensive review of the clinical laboratories in the Indian Health 
facilities across the country and to make recommendations as to a 
program systematically to upgrade the quality of these laboratories 
in a step-wise fashion over the next few years. We have also 
asked the National Communicable Disease Center to estimate for the 
cost of this upgrading. 
The original survey was done by the National Communicable Disease 
Center in October and November, 1968, and the recommendations 
have been received. They are the basis for the attached budget. 
The program plan for this upgrading of the laboratories consists 
of establishing a central laboratory for each Area, which will 
serve as consultant to Service Unit laboratories in upgrading 
services, training laboratory personnel, and providing continuing 
education for existing personnel. 
In the meantime, we are upgrading laboratory services by insisting 
that all clinical laboratories in the Indian Health Service 
participate in the quality control testing program of the National 
Communicable Disease Center. 
In every Area and in Headquarters a focal point has been designated 
to assume the leadership in this process of upgrading laboratory 
services. 18 
Project No. 10 (Cont'd) 
Proposed Budget: 
FY 
71 
FY 72 
FY 73 FY 
74 
FY 
75 
$923 
,000 
$1,297,000 
$1,228,000 $1, 
341,000 
$1 = 
,341,000 
April 30, 1969 19 
PROJECT 11 
EXPAND AND IMPROVE SCHOOL HEALTH CENTERS SERVICES 
The changing pattern in student cooperation in boarding schools hau moved 
towards a mandatory demand for expanded services to meet the psychological 
as well as the physical problems expressed within the student body. This 
changing pattern has also strengthened the concept that to provide health 
services in isolation from community development tends to fragment the 
community and its resources. Therefore, the use of the school health 
centers should be expanded to include and to be integrated with the health 
needs of the community adjacent to the school. 
To implement this project the following is proposed: a) The intensifica- 
tion of the mental health component of the school health center program and 
the inclusion of psychiatric social workers or mental health nurses on their 
staff, supported by consultant clinical psychologists and psychiatrists, 
b) The utilization through contract, where feasible, of local non-government 
resources and the consequent increase in contract health care funds, c) The 
expansion in the scope of the school health centers to include the care of 
the health needs of the community adjacent to the center, d) To intensify 
the involvement of the Indian parent in total community development, of which 
the health and welfare of the school age children is one important consideration, 
e) The development of a proto-type school health program in selected boarding 
schools preserving the proven accomplishment but changing, if necessary, the 
direction of the present program to make a truly integrated service for 
student growth and development, f) The construction and operation of 8 new 
school health centers at boarding schools and other medium-sized schools. 20 
Project 11 (Cont'd) 
Costs 
Assuming a conservative construction average o£ $400,000 per new school health 
center, an average operating costs per new center of $120,000 and $250,000 to 
improve the program in 17 school health centers already in operation, the 
F.Y, 1971-1975 costs would be: 
F. Y. 
19 7 1 
F. Y. 
19 7 2 
F. Y. 
19 7 3 
F. Y. 
19 7 4 
F. Y. 
19 7 5 
Construction oi 8 
school health centers 
(non recurrent) 
800,000 
800,000 
800,000 
400,000 
400,000 
Operations of the 8 
new school health 
centers 
240,000 
480,000 
720,000 
840,000 
960,000 
To improve the programs 
in 17 already built 
school health centers 
250,000 
250,000 
250,000 
250,000 
250,000 21 
Project No, 12 
PROVIDE EXTENDED CARE CAPABILITY 
Because of geographic isolation, low income status, unsatisfactory 
environmental conditions, and the sometimes rudimentary life in 
Indian homes, a need exists for providing care to chronically ill 
patients who are unable to return to their homes but who do not need 
hospital care. It is proposed that Indian Health Service provide extended 
care facilities at a ratio of five beds per 2,000 population and that 
specialized services such as social services, physical therapy, 
occupational therapy, rehabilitation and recreation services be 
provided. These facilities should be developed in proximity to 
hospital care and would provide 1,000 beds in total over this 
five-year period (200 per year). 
Costs 
FY 
FY 
FY 
FY 
FY 
1971 
1972 
1973 
1974 
1975 
Construction 
$8,000,000 
$8,000,000 
$8,000,000 
$8,000,000 
$8,000,000 
Operation 
1,752,000 
3,504,000 
5,256,000 
7,008,000 
8,760,000 
Cost of construction based on $40,000 per bed. 
Operation $24.00 per day per bed. 
April 30, 1969 22 
Project No, 13 
PARTICIPATE IN THE DEVELOPMENT OF A PUBLIC 
TRANSPORTATION SYSTEM FOR INDIANS 
Because the present lack of transportation has a serious impact 
upon the provision and delivery of health services, it is proposed 
that IHS participate with other agencies in the inauguration of a 
public bus transportation on five reservations. Government 
involvement would be restricted to contracting, financing and 
consulting activity so that tribal management is achieved. 
Costs 
It is recommended that financing be shared by Indian Health Service, 
Bureau of Indian Affairs, and Office of Economic Opportunity as follows 
Fiscal Year 
Agency 
1971 
1972 
1973 
1974 
1975 
IHS 
$100,000 
$150,000 
$110,000 
$115,000 
$130,000 
BIA 
100,000 
150,000 
110,000 
110,000 
130,000 
OEO 
75.000 
140,000 
110,000 
110,000 
130,000 
$275,000 
$440,000 
$330,000 
$335,000 
$390,000 
April 30, 1969 Proiect No. 14 
DEVELOPMENT OF MODEL COMMUNICATIONS SYSTEMS 
This is a four part proposal which would (1) link together IHS 
facilities in Alaska and Alaska villages ($300,000 over a five-year 
period), (2) implement the Navajo communications system which is 
BIA operated and which will tie into IHS vehicles and facilities 
(rental basis - about $100,000 annually), and (3) Install radio 
facilities on rental basis in IHS vehicles and stations elsewhere 
(annual cost $300,000), (4) study the feasibility of closed circuit 
television use in listing remote locations and a system of diagnostic 
and training capabilities with IHS and other facilities ($100,000). 
Coats 
1971 
1972 
Fiscal Year 
1973 
1974 
1975 
Alaska 
$70,000 
$50,000 
$75,000 
$75,000 
$75,000 
Navajo 
50,000 
100,000 
100,000 
100,000 
100,000 
Elsewhere 
225,000 
300,000 
300,000 
300.000 
300,000 
Total 
$345,000 
$450,000 
$475,000 
$475,000 
$475,000 
April 30, 1969 24 
Project No. 15 
PROPOSAL FOR REGIONAL REHABILITATION PROGRAM FOR NAVAJO AREA 
The proposal would emphasize a spinal cord treatment program and a total 
rehabilitation program on the Navajo where the incidence of such injuries 
is about double that of the U.S. population. The proposal would facili- 
tate an improvement in initial treatment of such injuries and would pro- 
vide needed follow-up care. A spinal cord unit would be set up under 
the program and emergency transport and treatment procedures will be 
developed by the medical staffs of the Gallup Indian Hospital and the 
Spinal Cord Center at Craig Rehabilitation Hospital in Denver. Referral 
to vocational rehabilitation programs will be arranged and those severely 
injured patients having no home to go to will be given a domiciliary 
placement adjacent to the home placement unit on the reservation. 
Cost 
FY 72 
”73 
FY lk 
nji 
$1*97, ooo 
$51+6,000 
$601,000 
$661,000 
$727,000 
Total Cost Per Patient = $16,530 
April 30, 1969 Project No. 16 
NEW TYPE OF HEALTH CARE DELIVERY SYSTEM 
Throughout this program report and plan there has been emphasized the 
expansion of the ongoing interaction of the provider of services and 
the Indian people as the user of those services in a program leading 
to true self-determination. Much more can be done within the existing 
system of health care delivery system. But to do so, without examining 
and rearranging that health system, which is under severe question in 
so many quarters (particularly for rural health) would assume that the 
system is perfect and all that is needed is. more delivery and more 
consumer participation and the health problems will be reduced. 
This proposal assumes that the present system automatically has two 
flaws. First, it was not designed with and through consumer partici- 
pation. Secondly, it was not designed to be tested against alter- 
native methods of delivery or to test the feasibility of the use of 
new technologies such as information and communication linkages. 
The proposal is to develop with tribal participation a prototype 
rural health delivery center in terms of (l) Its design, construction 
and environmental linkages (transportation, communication, etc.) and 
(2) Creating the opportunity to plan implement and evaluate (a) new 
methods of delivery, (b) new roles for health professionals, (c) new 
roles for existing sub-professionals and new types of such personnel 
with emphasis on entry mechanisms and career ladders, and (d) new 
roles for the consumer in the management of health programs. (Also see 
Project Nos. 5 and 8.) 
The planning would embody tribal participation and be consonant with 
area and regional plans. The location proposed is the Papago Reser- 
vation in Arizona. 
This R&IT effort would be coordinated with the IHS Health Program 
Systems Center, Office of Program Planning and Evaluation, and 
Training Center while providing a prototype and demonstration focus 
for the other IHS emphasis plans of value to the nation as whole and 
to developing counties. The requirement is for initial provision of 
an appropriate delivery facility and for continuing research and 
development. 
Costs 
FY 1971 
FY 1972 
FY 1973 
FY 197*+ 
FY 1975 
Facilities 
$150,000 
R&D* 
$250,000 
$250,000 
$250,000 
$250,000 
$250,000 
Total 
$if00,000 
$250,000 
$250,000 
$250,000 
$250,000 
* Research and Development 
April 30, 1969 26 
Proiect No, 17 
EXTENSION OF HEALTH CARE SERVICES TO SELECTED CALIFORNIA COMMUNITIES 
Of a total estimated population of 47,000, Indian Health Services 
are routinely provided to approximately 800 Indians residing on or 
near the Yuma Reservation, Approximately 6,000 reside on rancheros 
located in somewhat isolated areas of southern California and the 
remaining 40,000 live in the highly industrialized urban areas of 
San Francisco, Los Angeles, San Diego, etc. Instances of health care 
needs which are not being met through normal channels should be 
identified and assistance provided to augment the local and State 
services provided. Accomplishment of this could be handled primarily 
through contracts with local health resources and coordinated through 
the assignment of a Health Program Coordinator. 
Cost: 
FY 
FY 
FY 
FY 
FY 
1971 
1972 
1973 
1974 
1975 
$500,000 
$530,000 
$565,000 
$600,000 
$635,000 
April 30, 1969