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Indian health service director discusses challenges of doing more with less

December 15, 2011 — The Indian Health Service’s limited resources are both a sore point and a strength, says its director, Yvette Roubideaux.

They’re a sore point, says Roubideaux, AB ’85, MD ’89, MPH ’97—appointed head of the $4 billion-a-year agency in 2009—because it’s tough to offer competitive salaries to recruit and retain enough primary care physicians to work on Indian reservations. Likewise, it’s tough to adequately tackle high rates of lifestyle-related illnesses, notably diabetes, among American Indians and Native Alaskans.

But it’s a strength because other healthcare leaders in the United States could probably learn much from the Indian Health Service (IHS), she said.

“We can provide quality health care for much less cost—because we have to,” Roubideaux told a Harvard School of Public Health (HSPH) audience on December 5, 2011, as part of the “Decision-Making: Voices From the Field” speaker series sponsored by the Division of Policy Translation and Leadership Development. “My budget of $4 billion sounds like a lot,” said Roubideaux. “But when you think about NIH [National Institutes of Health] and their hundreds of billions of dollars and the entire budget for Health and Human Services, we’re just a small part of it. And if you look at the disparities we face, it makes sense as to why the Indian health system needs support. We have people who are living in [developing world] conditions on our Indian reservations.”

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At the IHS, she said, the focus is not only on what happens in the clinic, but also on social determinants of health, such as poverty or poor education. Focusing not just on the patient but on the community and the culture as a whole is the best way to provide health care, and can also save money by focusing on prevention. “That’s probably the greatest lesson we could give to the rest of the United States.”

For instance, Roubideaux noted, while Native Americans are unlikely to attend an information session on diabetes—“they have a lot of other priorities to deal with,” she said—they would attend a beadwork or basket-making class. So now the IHS has diabetes educators visit those types of classes to talk about the disease while students work on projects. “Those classes have been very well received,” she said.

Roubideaux was a doctor for the Indian Health Service in Arizona for several years before coming to HSPH to earn her master of public health (MPH) degree. For about a decade after that, she conducted research on diabetes and quality of care.

Upon her arrival at IHS, Roubideaux asked her colleagues, tribal leaders, and patients about their major concerns. She thought most would cite the poor quality of care—a longstanding problem for the IHS—but instead most discussed the need to improve the way the IHS conducted business, and to improve how it led and managed people.

“People felt that they couldn’t provide good care because of the administrative dysfunction,” Roubideaux explained. “It helped me to know that we had to work on some very basic and fundamental things,” she said, citing customer service, professionalism, fairness, training, budget management, and decision-making.

“It turns out that making improvements in those areas has actually improved our ability to provide clinical care,” she said. “We have much more to do. But I think it’s a step in the right direction.”

–Karen Feldscher

photo: Steve Gilbert