The Government Performance and Results Act in a Nutshell:

Implications for the IHS and its Stakeholders

*February 2000*

What is It?

The passage of the 1993 Government Performance and Results Act (GPRA) or
the \"Results Act\" may prove to be one of the more profound changes in
Federal government accountability. This law requires Federal agencies to
demonstrate measurable results or benefits gained by the consumers of
Federal programs. In addition, these results must be accomplished in
such a way that there is a clear audit trail from funding/appropriation
to the activities or outputs of Federal agencies, and ultimately to the
results or outcomes of these activities.

While Federal programs have experienced a number of management
directives over the past few decades such as \"Zero-Based Budgeting,
Management by Objectives, Total Quality Improvement and Continuous
Quality Improvement, none of these initiatives were statutes unanimously
passed by Congress. Rather than drifting into the background as others
all have, the GPRA and its related statutory requirements are being
increasingly focused on by Congress and the Executive Branch (including
the Office of Management and Budget or OMB), in making funding
decisions. Clearly the GPRA and what can be called the \"era of
performance management\" is a reality for today\'s Federal organizations
and those they serve.

What Does it Require?

Another way to view the GPRA is as a mandate for Federal programs to use
systematic planning and evaluation. In this light, the law has three
basic requirements: 1) a strategic plan covering a five-year span; 2) an
annual performance plan, and 3) an annual performance report. The
strategic plan must spell an agency\'s mission, goals, and approach to
accomplishing them as well as overview factors influencing success. At
this point in time, the IHS is not required to develop its own
independent strategic plan, but contributes to the Department\'s more
global strategic plan. However, the IHS drafted its own strategic plan
for internal use and to underpin the annual performance plan. To a large
extent the IHS Strategic Plan is based on the recommendations of the
Indian Health Design Team, a group of stakeholders the IHS Director
empowered in 1995 to develop the plan for the reorganization of the IHS.

The second requirement of GPRA is the annual performance plan that
represents the real demands of the law. Each agency in DHHS is required
to submit an agency-specific annual performance plan with the submission
of its budget request. Preparing this annual performance plan is a
complex process that requires selecting performance indicators that
represent commitments to accomplishing meaningful \"results\" for the
major funding categories in the IHS budget. The issue of how demanding
should we make the indicators (i.e., how high to set the bar) has no
simple answer. There are two extremes we need to avoid in selecting
performance indicators. The first is setting a level of attainment that
is perceived by Congress, the Department, or OMB as minimal or weak, and
could thus lead to a lack of support for funding requests. On the other
hand, if we select indicators beyond our capability to achieve, we can
demoralize staff and risk future funding support because of failing to
meet our commitments.

The development of the annual performance plan in the IHS is linked to
the budget formulation process which begins at the local level, moves to
Area level, and finally to a single IHS budget request. For the past
three budget cycles, performance indicators have been selected to
support the funding priorities identified by stakeholders in this budget
formulation process. Additional input in selecting indicators has been
gained by consulting with clinical, epidemiology, and statistical/data
experts. As much as possible, indicators are selected which do not
require additional data collection efforts. The FY 1999 IHS Performance
Plan was made up of 27 indicators, the FY 2000 IHS Final Performance
Plan contains 34 indicators, and proposed FY 2001 Annual Performance
Plan has 37 indicators.

The last requirement of the GPRA law, the annual performance report,
basically provides an answer to the question: how did the agency do in
accomplishing its performance plan? In addition to reporting on the
level of attainment of each performance indicator, the annual
performance report allows an agency to discuss the factors that assisted
or impeded the accomplishment of the indicators. The first annual
performance report (for the FY 1999 performance plan) was required to be
included with the Congressional submission of the FY 2001 budget request
in January of 2000.

GPRA and the IHS: Challenges and Opportunities!

The IHS and a growing number of its stakeholders have embraced the GPRA
as an opportunity since what it mandates is essentially the same
planning and evaluation processes that good public health programs have
used for years. While the GPRA is a good fit for a public health agency,
it is more difficult to execute in a decentralized agency such as the
IHS. The IHS can submit only one performance plan and one set of
performance indicators for all IHS, Tribal and Urban Indian (I/T/U)
programs. Successfully accomplishing GPRA in the IHS will be a challenge
because of the loss of public health infrastructure that has occurred as
a result of absorbing over \$400 million in mandatory cost increases
since 1992, and the growing trend of decentralization and increasing
tribal management of local health programs. While the IHS is responsible
for reporting to Congress and the Administration on all Indian health
expenditures, Tribal programs do not have to provide GPRA data to the
IHS. Thus the challenges the IHS must face in implementing GPRA include:

-   identifying indicators that are broadly accepted and supported
    across local I/T/U programs and for which data are available

-   compiling data for performance indicators from diverse and sometimes
    poorly compatible data systems

-   securing an adequate representation of Tribal program GPRA data, on
    a voluntary basis, to satisfy Congress, OMB and the Department

-   successfully achieving and documenting the level of attainment
    proposed in annual performance plans

Despite these challenges, the GPRA process in conjunction with the
budget formulation process has served Indian health well thus far in two
important ways. First, the GPRA/Budget Formulation process has increased
collaboration and understanding of public health and budgeting across
the diverse IHS stakeholders. Clearly the process of addressing these
issues beginning at the local level and moving up has aligned and
mobilized tribal leaders and consumers about funding issues that address
significant public health problems. In this process health program staff
have learned more about the IHS budget process and budget/finance staff
have learned more about public health. But probably of most importance,
tribal leaders and consumers have learned more about both public health
and budgeting, and used this knowledge within the political system to
speak with a more unified voice, supported by data, to justify funding
enhancements.

The second benefit of the GPRA/Budget Formulation process is the results
that were realized with the President\'s proposed FY 2001 budget for the
IHS. For the second year since FY 1992, the IHS proposed funding level
includes an emphasis on the mandatory cost increases plus several
program enhancements, and puts the IHS at the top of the Department\'s
priority list in FY 2001. Based on feedback from OMB and the Department,
it is clear that the strength of the IHS annual performance plans for
FYs 1999 and FY 2000 were positive factors in their support for FY 2001
funding enhancements. In addition, several sources of anecdotal data
strongly suggest that the frequency and consistency of tribal input
directed towards the Department, Congress, and OMB also contributed to
these enhancements and will be even more important as the IHS budget
moves into Congressional hearings.

GPRA and the Future of Indian Health Issues

FY 2000 is certainly an important and demanding year relative to GPRA.
For the first time we have submitted a report on the I/T/U performance
in comparison to the targets we set for ourselves in the FY 1999 annual
performance plan. We are in the process of executing the FY 2000 annual
performance plan, revising the FY 2001 annual performance plan, and
beginning to draft the FY 2002 annual performance plan. From the local
I/T/U to IHS Areas and Headquarters the learning curve has been steep,
and the needed efforts are clearly increasing as all signs and
indications from the Department, OMB, and Congress continue to point to
an increase focus on GPRA. Given the Administration\'s current policies
and initiatives relative to eliminating racial and ethnic health
disparities, the IHS can continue to use the GPRA process to leverage
increased resources to address the significant disparities in health
status American Indian and Alaska Native people experience. However, we
must be able to document \"results\" as part of the process. Indeed with
reasonable funding and support of our diverse stakeholders we can and
will.

In a nutshell, the GPRA is a good law that actually allows the IHS and
its stakeholders to define what is important to accomplish relative to
the health of the American Indian and Alaska Native people. It requires
that we be accountable for accomplishing our mission, and certainly we
should be. Likewise, the Federal Government must meet its obligation to
provide reasonable funding support to this end. Policies about
disparities are meaningless without the resources to address them. To
succeed in this effort will require a high level of collaboration and
cooperation from all levels of the Indian health system. Specifically,
everyone is encouraged to:

-   participate in GPRA/ Budget Formulation activities to define funding
    and performance priorities

-   advocate for and support the GPRA process at all levels but
    particularly the I/T/U level

-   advocate using consistent valid data for needed appropriations
    through all available legal mechanisms