Developing an Indigenous systems alignment framework: A call for direct funding

Native nations and Indigenous health organizations have a long history of aligning health care, behavioral health, public health, and social service systems, though peer-reviewed literature examining tribal systems alignment is limited.1-6 Treaty rights, trust responsibilities, and legislative actions guarantee the exchange of Indigenous peoples' land and natural resources for health care, education, and other critical programs from the U.S. federal government. However, limited funding for systems strengthening has resulted in significant unmet needs within Native nations and Indigenous communities.7, 8 Despite the dearth of resources, the health systems serving Native nations and Indigenous communities have identified innovative, culturally congruent, and collaborative approaches that meet community goals and needs efficiently and effectively.9, 10 The effectiveness of the approaches taken by Native nations and Indigenous community health (ICH) organizations is attributed to customary relationships between tribal leaders and citizens and engagement as rightsholders in partnerships with non-tribal and governmental entities.1-10 With direct funding, Native nations and ICH organizations can continue to build upon this evidence, tackle structural barriers, and further their engagement in systems and implementation science research. This commentary shares evidence that demonstrates how direct funding can enhance Native nations and Indigenous community (NNIC) driven research using Indigenous systems alignment frameworks and improve long-term collaboration with internal and external, cross-sector partners (e.g., tribal government divisions, nonprofit community health clinics, etc.). The following section provides a description of the Georgia Health Policy Center (GHPC) Framework for Aligning Systems (Framework), health systems serving Native nations and Indigenous communities, and study findings. The findings from the Indigenous health systems: Revitalizing Inherent Alignment (Indigenous Systems Alignment) confirm cultural and political status attributes that strengthen long-term collaborations for community health. The Indigenous Systems Alignment study was designed to consider the relevance and applicability of the GHPC Framework for health systems strengthening within Native nations and ICH organizations. Within the U.S. health care delivery system, various models (e.g., wrap around services, accountability homes, etc.) have been developed to address social determinants, improve access, and improve the quality of care for individual- and population-level health, with varying impact.11-14 The GHPC Framework, Figure 1 below, offers a unifying pathway across sectors (e.g., health, public health, social services, etc.) to collaboratively implement strategies for sustained alignment, with the goals of health equity, racial equity, and outcomes defined by community.15 The strategies take into account context of shared systems (e.g., governance, finance, data, and shared purpose) and the relationships (e.g., community voice, trust, equity, and power dynamics) that ensure their sustainability and success.15, 16 The advantage of the GHPC Framework is its generalizability and adaptability to community and local contexts. with permission from the original authors. The next section provides context for examining the GHPC Framework for health systems strengthening (i.e., translational and implementation) research and initiatives within the diverse and interconnected U.S., Native nations, and Indigenous community health systems. NNIC are not monolithic nor are they completely disconnected from the U.S. health system (e.g., Indian Health Service, U.S. Veterans Affairs, Medicaid, Medicare).7, 8 The complexity and diversity of the systems come from the government-to-government relationship and trust responsibility that the U.S. federal government has with Native nations, which are comprised of 576 federally- and 220 state-recognized American Indian and Alaska Native nations, tribes, pueblos, and villages.7 As the federal government grew and shifted, so did the degree of consultation and services that Native nations received. At the same time, federal legislative acts and policies have simultaneously upheld U.S. trust responsibilities with respect to tribal nations, while others have been tools intended to assimilate American Indians and Alaska Natives within the broader U.S. population. The passage of Public Law (PL) 93–638 in 1975 brought a new era of tribal sovereignty and governance. Recognizing tribal sovereignty, PL 93–638 ensured Native nations the right to design and fund education and health systems that best served their citizens and community members.8, 17 In effect, PL 93–648 provided for Native nations to maintain systems for healing and being well that are and have been effectively aligned with the tribal worldviews and ways of being since community inception.18 Due to this history and context, governance of public health, health care, and social services sectors within Native nations fall under one government system. This is both a strength and challenge. Native nations and ICH systems are siloed by funding and fragmented data systems. Within the context of tribal political and cultural sovereignty and existing shared systems, the Indigenous Systems Alignment engaged tribal partners in a practice-based study of cross-sector alignment. The Indigenous Systems Alignment project provides a case study to examine the GHPC Framework's relevance and applicability to systems alignment within Native nations and ICH systems. In 2020, Seven Directions, an Indigenous public health institute at the University of Washington (UW); in collaboration with Red Star International, Inc., a non-profit organization with Indigenous public health expertise; and five tribal partners received a two-year Aligning Systems for Health Initiative grant from the GHPC, funded by the Robert Wood Johnson Foundation (RWJF). Seven Directions was the only Indigenous organization among seven total recipients of the grant. Indigenous Systems Alignment was a practice-based, mixed-methods, study of cross-sector alignment (i.e., public health, health care, and social services) within the context of Native nations and ICH organizations. The research questions were descriptive: What does cross-sector alignment for health look like within the tribal partners' respective systems? And how does alignment within Native nations / Tribal entities inform (confirm or refute) the components of GHPC's Theory of Change? The study followed community-based participatory research principles that included embedding reciprocal knowledge exchanges in the study design. This practice-based design ensured relevance of the study for the five participating tribal partners (four Native nations and one Indigenous health organization) from across the U.S. A tribal technical committee advisory group provided feedback on study methods that included dimensions from the GHPC Framework.16 From 2020 to 2022, Tribal partners were invited to establish Tribal Transformation Teams (T3) that represented public health, health care, and social services. T3 members were invited to participate in research activities and attended regular technical assistance sessions. The T3 teams (approx. 6–8 members each) represented tribal administration, public health, health care, social services, and information technology. Not all T3 members participated in the research activities. Following UW and Tribal research review and approval, T3 team members participated in interviews (40–50 min) and surveys (20–30 min), at two time points. From April to November 2021, 18 interviews and 19 surveys were collected, and from February to June 2022, 18 interviews and 22 surveys were collected. Findings, that represent four of the five tribal partners, were strengthened by a triangulation of data sources, a mixed methods approach. The study launched at the onset of the Covid-19 pandemic, and tribal partners' teams were immediately called to respond to the public health emergency. The small sample size is a limitation, and the study is not representative of all tribal cross-sector systems. A full description of the study methodology and findings may be found in the Georgia Health Policy Center's Aligning Systems for Health: Research Learnings from Across the Nation.19 The next section shares findings from the study that respond to research questions and describe cross-sector systems alignment within the context of NNIC health systems. The Indigenous Systems Alignment study findings confirm the relevance and applicability of the GHPC's Framework, Figure 1. Yet, the interpretation and understanding of the Framework elements from Indigenous worldviews, political sovereignty, and lived realities also contribute to an emerging Indigenous Systems Alignment Framework, which is complementary to and distinct from GPHC's Framework. This section describes selected Indigenous Systems Alignment findings: Accountability to Community, Tribal Governance, and Tribal Data System Development, that represent a parallel and intersectional contribution to the field of systems alignment. They reference the GHPC Framework, Figure 1, specifically the components of shared systems (e.g., purpose, data, and governance) and internal-external relationships (e.g., community voice, trust, power dynamics) for long-term collaborations toward community defined outcomes.15, 16 Accountability to Community refers to a sense of responsibility and obligation to serve community that extends beyond professional duties to customary roles for tribal and community members working for Native nations. Within the GHPC Framework, Figure 1, it is most closely associated with relationships that center community voice, trust, and power dynamics within aligned systems for community health needs and goals.15, 16 T3 participants, who were all either tribal employees (tribal and non-tribal members) or consultants were, asked to share their role, position, and connection to the Native nation or Indigenous health organization. T3 survey respondents shared that they often or always felt a sense of responsibility to work in service to their community (94%). One tribal member shared, "This is where my parents live and where my children are being raised, if I want things to get better here, I gotta be part of that change" (Interviewee, Manager, 2022). This connection was also shared by non-tribal team members who described their connection came from living in the community or having worked there for many years. A tribal administrator expressed a similar non-transactional relationship they had in their role. They shared, "Most know that they administrators are in it for the long run, they have to have a lot of patience with how well you are doing or not doing" (Interviewee, Administrator, 2022). These quotes illustrate the value and practice of relational and community accountability within Native nations and Indigenous communities that directly impact alignment across sectors. Tribal governance refers to the power to effect change within a tribal system through resolutions, laws, and policies. These rights are innate and inherent to Indigenous peoples as rightsholders within sovereign nations. Tribal leadership exercise governance by carrying out the expected roles and responsibilities for their position, including those associated with public health authority. Coming from a bureaucracy where if somebody wants to talk about something it goes in one ear out the other, here people are allowed in council meetings to express their concerns for five minutes, ten minutes, 20 min, or an hour. They Tribal Council let them. I just love that because you're letting them (tribal and community members) know that they're worth listening to. (Interviewee, Administrator, 2021) Acknowledged within this quote is a relational and non-transactional approach to governance. Through active listening, tribal leaders demonstrate their commitment to act with accountability to their community. Tribal governance is specific to an Indigenous systems alignment framework. It also expands the existing GHPC Framework. Tribal leadership ensures existing shared systems for data, finance, and governance are monitored and maintained to meet community needs and goals. This approach to governance informs support for tribal-wide, cross-sector initiatives such as tribal data systems alignment. Tribal data systems development requires data governance, infrastructure, and capacity building. T3 participants reported being at various levels of interoperable data system development (82 percent). A T3 participant shared how an interoperable data system would be beneficial for accessing cross-sector data: "Community Health Assessment helps us…talking about social determinants. Where is the data that helps make those connections? how can we get that data to make it a full picture of name of Tribe" (Interviewee, Administrator, 2022). This quote refers to cross-sector data used for public health performance management (PHPM). Data for governance would come from assessments, community health improvement plans, and strategic planning. It may be collected across sectors to measure benchmarks toward shared goals within the PHPM system. This becomes important cross-sector data that leadership can use for decision-making and governance for community health and wellbeing. The findings in this section support cross-sector alignment that values relationality, ensures tribal governance, and emphasizes tribal data systems development. The Indigenous Systems Alignment study findings provide a relational understanding of accountability to community and center the development of a shared tribal data system for cross-sector alignment. Given this centrality, Indigenous data sovereignty and governance (IDS/IDG) it is important for Native nations, Indigenous communities, and collaborating partners to engage in cross-sector alignment initiatives. Indigenous data sovereignty and governance refers to the rights of Indigenous peoples to define, collect, protect, use and share their own data (i.e., data stewardship across data ecosystems).20-22 The phrase "Indigenous Data for Governance and Governance of Indigenous Data," represents the bi-directional relationship among tribal leadership, managers, and program teams that is needed to develop and benefit from a robust tribal data system.21 An example of cross-sector alignment of tribal data systems is the Coeur d'Alene Tribe's (CDA) Tribal Care Coordination Dashboard Project: Coeur Adolescent Support Team study. It is a 12-month study funded through Systems for Action (S4A), by the RWJF. The CDA Tribe received funding directly to pilot a program-specific referral and dashboard system. The long-term goals are to establish the required data sharing agreements, create a universal intake form, and develop a dashboard that reports on progress toward tribal-wide, community wellness goals. A strong cross-sector tribal data system can redress the fragmented and siloed systems that resulted from lack of funding for Native nations and Indigenous community organizations.23 Examples exist of working across jurisdictions in partnership to establish the agreements to improve access to reliable data.24-26 And increasingly the Collective Benefit, Authority to Control, Responsibility, and Ethics27 (CARE) principles that guide access and use of Indigenous data are being used to review data agreements, linkages, codes and integrated into research proposals.26 Sustainability of these efforts will come from establishing standards at the national level and within Native nations to guide policy development and best practice.27 Placing Indigenous systems alignment within the context of the IDS/IDG movement points the way toward future research and policy development. Grounding cross-sector health systems strengthening research within the IDS/IDG movement, specifically for tribal data system development, requires direct and substantive funding of Native nations and ICH organizations. We propose the following five recommendations for research and practice. They are: first, increase awareness and access to calls for health service research and cross-sector systems alignment proposals; second, change government and non-profit funding mechanisms to provide for direct submissions by or allocations to Native nations and Indigenous health organizations; third, use practice-based or participatory research approaches to privilege Indigenous knowledge and center community; fourth, ensure studies are funded at a level that allows for sufficient time for relationship building and tribal research review processes; and fifth, train non-Indigenous partners in tribal sovereignty, trust responsibility, self-governance, and Indigenous data sovereignty/governance. These recommendations support a call for direct government and non-profit funding to Native nation and Indigenous health organizations to continue research to develop and use an Indigenous systems alignment framework that best serves their communities needs and goals for long-term impact of improved quality, access, and use of services. Support for this article was provided by Georgia Health Policy, Georgia State University, through by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.