Results in Brief

Administration in this contracting process. In addition, GAO sent a questionnaire in November 1985 to all federally recognized Indian tribes and tribal organizations seeking their opinions on contracting under Public Law 93-638 to operate health care programs.

The majority of Indian tribal contractors GAO visited had problems working with IHS in obtaining and administering contracts under Public Law 93-638. These problems, usually disagreements between IHS and the Indian contractor over the subject matter or the level of funding for the contract, resulted in delays in completing the administrative contract process. According to Indian contractors and IHS officials, however, the delays in contract administration did not result in loss of health care services to Indian tribal members. GAO also determined that the Health Resources and Services Administration's involvement in IHS's contract administration process did not interfere with IHS's approval authority under Public Law 93-638.

Indian self-determination has not been achieved, according to the majority of Indian contractors GAO visited and the majority responding to GAO's questionnaire. Indian contractors perceive the law as giving them the opportunity to determine for themselves the manner in which health care services should be delivered, and they see IHS restricting this freedom by various contract regulations. IHS views self-determination as Indian tribes being able to operate IHS activities through contracts as stated in the law. GAO concurs with IHS's views.

Principal Findings

Delays in getting contracts reviewed or approved were attributed by tribal contractors to reasons ranging from difficulties in following contract requirements to disagreements with IHS on the subject matter and/ or the amount of funds for the contract. Also, IHS has no procedures for developing a contract for facility construction under Public Law 93-638. Among the reasons given by IHS for delays were the lack of sufficient personnel to review contracts and procedures to follow in the review process.

Equipment Acquistion
Sometimes Delayed

Of the 12 contractors GAO visited, 9 expressed concerns about delays in equipment acquisition for items ranging from office computer equipment to X-ray machines. Three did not believe there was a problem with equipment acquisition. The delays occurred because time was needed to

Executive Summary

Scope of Work Under Nine
Contracts Incomplete

follow the required review process and/or funds were not available to acquire the equipment.

The scope-of-work sections for 9 of the 12 contracts GAO reviewed were incomplete. For example, the contracts did not identify the number of Indian people to be served or the manner in which the contracts were to be evaluated.

Comments from the four local IHS contracting officials indicated that regular visits to the contractor's activity were sufficient to determine contractor performance. GAO did not measure contractor performance because it was beyond the scope of this assignment but believes that a clearly defined scope of work specifying what, when, and by whom services are to be provided needs to be precisely identified along with the intended beneficiaries of this service.

Self-Determination Viewed
Differently

To give Indian tribes the greatest possible role in administering health care programs that affect them, Public Law 93-638 allows tribes to contract with IHS for health care activities previously operated by IHS or for new activities not previously provided. Seven of the 12 tribal contractors visited by GAO said that they have little if any say in the health care to be delivered or the funding of their contracts. In addition, they told GAO that IHS has resisted adding new health services, providing services differently than previously provided by IHS, or shifting funds within a contract. A majority (65-78 percent) of the tribal contractors responding to GAO's questionnaire expressed similar views.

Indian contractors and IHS view the law somewhat differently. Tribes generally appear to believe the law allows them to provide health care activities with little intervention from IHS. IHS, however, sees the law as requiring it to assure that adequate health care is provided and that all applicable contract administration procedures are followed. Despite this difference, Indian contractors and IHS officials provided no evidence that Indian tribal members were not receiving health care services.

While Public Law 93-638 attempts to enhance Indian self-determination and increase Indian participation, GAO believes that the contracting process as defined by the law and regulations must be followed and that IHS is responsible for the contracts under the law.

Agency Actions Taken

In April 1986, IHS and the Health Resources and Services Administration developed an initiative paper for review and comment by IHS field offices and tribal entities. This paper proposed to (1) develop procedures for tribes to follow in developing construction contracts under Public Law 93-638, (2) reduce review time for equipment acquisitions, and (3) reduce contract requirements giving tribal contractors more judgment in use of available Public Law 93-638 contract funds.

GAO is making no recommendations.

Recommendations

Agency Comments

HHS stated that the report provides a comprehensive view of contracting under Public Law 93-638. It also stated that the Public Health Service Office of Management had recently completed a study of contracting problems under the act and that HHS had initiated a number of changes discussed in this report.