A Future of Possibilities

for Health, Indian Health, and Indian Health Leaders

by Tony Kendrick

"Good morning, Mr. President, the tribal delegations will be here this afternoon to discuss the proposed budget and the block grants to tribes," said the Secretary for the Department of Indian Trust. "Also on the agenda is their proposal for the Indian Health Service budget and request for additional employee support."

The above scenario is only one of the futures that were envisioned during a training session of 37 Indian Health Service managers and supervisors, doctors and nurses, and tribal and urban health representatives. The purpose of the training was to consider current issues, trends, and developments to envision possible futures for the Indian health system, to share ideas about the future, consider the challenges that will face future leaders, define characteristics and qualifications future leaders will need, and determine what actions can be taken to support leadership development. This article summarizes some of the ideas that came out of the training. It is also meant to provide insight of how leadership and the future is viewed by current leaders and managers. The information in this article may be useful for planning and making career decisions regarding performance, education, assignments and job experience for those who desire to assume a leadership role.

The leadership of the Indian Health Service has considered options for preparing the Indian health system for the leaders of the future. One of the roles for today's leaders is preparing others to replace them or to support those who will fill the future new positions in an organization that is evolving.

An exercise that helped in the process of envisioning a future was for each individual to write a letter to a grandchild. The content of the letter was to describe the legacy they left for a grandchild or a grandchild not yet born.

Challenges
In almost every discussion there was a sense that budget levels will continue to decline. It was noted that a stable budget is a declining budget because of increasing costs to pay for services, maintenance, construction, and personnel. The leadership challenge of how to provide these services with a declining federal budget to an increasing American Indian and Alaska Native population appeared to be a major consideration for envisioning futures for the Indian health system and its leaders. Another theme that predominated in considering the future was that there would be increased tribal control of federal programs.

Health Delivery Systems
The options resulting from various brainstorming sessions and discussion were varied. A future option discussed was that the tribes would establish and operate an Indian Health Maintenance Organization (HMO). Another aspect is that the Indian Health Service would be one of many referral agencies for the Indian HMO. A source of revenue for the Indian HMO would be to accept fee paying non-Indian clients.

Another future possibility that was considered is the creation of a cabinet level Department of Indian Trust. It would bring together all Indian programs and allow for closer coordination with other departments on issues, programs, or decisions that impact Indian people. A variation of the cabinet level concept is an independent agency similar to the U.S. Postal Service, wherein the Indian Health Service is the federal component of a larger organization that is unfettered by federal regulations and could engage in business practices for the benefit of Indian health and programs. Still another possible future is the establishment of an Indian Nations organization similar to the United Nations; possibly an expansion of the National Congress of American Indians to a National Congress of Indian Nations.

Partnership Possibilities
The concepts considered for the role of the Indian Health Service in a future predominated and defined by tribal priorities were advocacy, budget development, and liaison between tribes and the Department. As a cost savings measure, tribes would continue to employ federal employees in tribal programs through Intergovernmental Personnel Agreements or Memorandum of Agreements. Employees hired to work in tribal, and possibly urban programs, would be selected by the tribal or urban program where the work would be performed. There would be a limited number of Indian Health Service positions needed to carry out residual federal functions, and tribal representatives would be included in the selection process.

The Director of the Indian Health Service will continue to be a Presidential appointee, an American Indian or Alaska Native, and tribes will be involved in the nomination process. However, the particular discipline of a future Director would not necessarily have to be in the medical field.

Regionalizing tribal and urban health centers might be a possibility, along with an Indian Health Service support component. The primary role of the Indian Health Service in a regional center would be one of support for local health programs, whether federal, tribal, or urban. Significant in this concept is that the Indian Health Service is a part, not the only part, of a tribal regional center for Indian health. The center is an opportunity for tribes and urban programs to leverage their resources. The center provides technical assistance to Indian health programs and also advocates for resources with federal agencies and programs, state government, private foundations, and even other countries. The overriding focus is meeting the health needs of Indian people through a combination of resources. The Indian Health Service component of the regional center would provide residual federal function support to tribal and urban programs.

The Indian Health Service would also provide services selected and funded by urban, tribal, and federal components of the health system. Some of those services, which would be costly if each health program had to duplicate the service, might be an overall facilities maintenance program, environmental health support, payroll, personnel and administrative services, collections, etc. This regional concept supports a move to establish an independent agency like the U.S. Postal Service. If the tribal and urban regional centers are not co-located with the Indian Health Service Area Office there would still be possibilities for providing federal support, and representation, at the tribal-urban regional centers.

Future Leaders
There was considerable discussion regarding the characteristics a future leader in Indian health should have. To be an effective leader the individual would need to be a diplomat, well mannered, respectful, and project a healthy image. They must possess an education or experience level that reflects an intellect for a wide range of issues and a curiosity for gaining new knowledge. Communication skills were considered critical, to the extent of being characterized as "must be a great communicator." As part of communicating, the individual must have marketing skills and be able to persuasively articulate issues or positions. They also must be able to relate well to a diverse population and workforce. Getting along with others is crucial for carrying out the advocacy role for Indian health. Leaders for Indian health must be creative and have an ability to envision a future. They must have a sense of humor, possess wisdom, have outside interests, and have integrity, fortitude, and, when necessary, the guts to take a position and defend it.

In addition to leadership characteristics, those attending the training also identified individual competencies that are needed by a future leader: negotiating skills, fiscal management knowledge and experience, experience with managed health care, knowledge of the federal system, knowledge of public health, and some health care experience. Other competencies that would increase the competitive position of an individual for positions of leadership include fund raising, grant writing, networking ability, public relations skills, and a knowledge of government, private, and industry funding sources. Personal qualities for leadership in Indian health include cultural sensitivity, flexibility, patience, creativity, and loyalty to the organization.

Leadership Development
A leader for Indian health must also want to be a leader for Indian health. There is no way of identifying future leaders, only those who appear to have the characteristics of a leader. A future leader results from self-selection. Self-selection takes many forms, but usually it shows up in an individual's performance. Once someone makes leadership in their field a personal career goal, they must begin to manage their career. They need to position themselves to qualify for selection to training programs, positions, special assignments, and leadership development programs.

To increase the opportunities for leadership, a person needs to identify current positions they prefer to consider as a future option and examine the qualifications of the person that now occupies the position. Should an individual career goal be to become the Director of the Indian Health Service, the individual must look at the career and qualifications of those who have held that position -- and the environment of the time in which they served. For example, Dr. Trujillo was appointed by the President to the position of Director and among his qualifications is that he has a medical degree, field assignments as a physician, and a progression of assignments of increasing responsibility in managing health programs leading to being a Chief Medical Officer for an Area. These are only some of his qualifications and experience, what is not on a resume is an individual's personal leadership qualities and vision. A future Director may not be a physician but could be a health administrator with similar assignments; field, hospital, headquarters, Area Director, for example. It is unlikely that, for example, a career spent entirely in one location would be as competitive for senior leadership roles outside of that location or specialty.

Selecting one possible future eliminates other futures. For example, while not outside the realm of possibility, selecting a career path to become a lawyer would eliminate a future where the individual would become the director of health programs, the head of an urban health program, an engineer, or a nurse. Choices for leadership roles and career should include infrastructure positions of support in the health industry and the Indian Health Service.

Future leaders are not just in the Indian health field. Leaders for Indian health are within all areas of government, academia, business, international affairs, tribal government, and Indian organizations, to name a few. The idea of developing future leaders should be shared with organizations outside of the Indian Health Service to gain their support, ideas, guidance, and participation.

Commitment of Support
Those choosing a leadership role can be supported by the Indian Health Service in a variety of ways. An employee exchange program between Indian Health Service, tribal, and urban programs is a possibility worth exploring. A detail or temporary rotational assignment in the office of a current leader or supervisor is a way to help an individual make the choices necessary to become a future leader.

Supporting local community schools is a program many government agencies participate in. Support is provided by employees serving as guest speakers or instructors and can participate in school career day events. Some employees teach remedial classes after hours on computer skills, English, math, science, and get involved in school activities. This program is an excellent way to role model for students and present future career considerations for them.

In addition, there is a commitment for various training options that match employee performance and career goals with training opportunities. An area for exploration is establishing a training relationship with universities and colleges -- particularly tribal community colleges. The colleges would develop leadership curriculums that support the Indian health vision of the future and provide the educational basis for leadership.

The commitment to leadership also extends to encouraging current managers and supervisors to conduct a self-assessment of their commitment to developing future leaders and their commitment to assisting in the development of a corporate culture than values employee growth and development. There was general agreement that the hardest part of developing leaders is to let the best people go on developmental assignments.

The future Indian health system is the legacy that is made each day. Write a letter to your grandchildren, telling them what you did today for Indian health that made their world better. Make them proud of you.

Tony Kendrick is the Director of Public Affairs for the Indian Health Service.