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Native Nations Reshape Rural Health Care Through Tribal Governance [1]
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Date: 2025-08-18
For decades, the Indian Health Service ran health care in Native American communities. Now, a growing number of tribes are reclaiming control of those systems, asserting their sovereignty in ways that are reshaping how care is delivered on rural reservation lands and beyond. In South Dakota, the tribally-owned Oyate Health Center has outperformed Indian Health Services in its revenue generation, expanded access, and made space for cultural tradition in its delivery of care.
“What has been really exciting in the last few years is seeing our tribes in the Great Plains reevaluate what sovereignty means in the space of health care,” said Jerilyn Church, chief executive officer of the Great Plains Tribal Leader’s Health Board (GPTLHB). Church spoke during the “Building Sustainable Futures for Tribal Communities” panel at the 2025 Rural Progress Summit, a national event that brought together rural advocates, local leaders, and policymakers to address key issues facing rural communities. “It makes a huge difference when it’s your own community members, your own tribal members, running and taking ownership of health care.”
The Oyate Health Center in Rapid City, South Dakota, is operated by the GPTLHB on behalf of the Oglala Sioux Tribe, Cheyenne River Sioux Tribe, and Rosebud Sioux Tribe. Beginning in 2019, the GPTLHB assumed control of the former Indian Health Service Rapid City Service Unit and Sioux San Hospital and opened Oyate Health Center. As an arm of the GPTLHB, which advocates for the health and wellness of 18 Great Plains tribes, Oyate represents a significant step in tribal control of health care and improving services for tribal communities in the region.
“Nobody loves our community and our relatives like we do,” Church said. “No one’s going to look out or take care of our health system and advocate for our health systems like we will.”
“We have been able to bring in a cultural advisor, not only for our staff, but also for our community members who on their health journey want to work side by side with their primary care provider and also a knowledge keeper [or] traditional healer,” Church said. Oyate Health Center’s cultural advisor has helped plan a community garden and taught traditional food practices, like buffalo harvesting, to promote nutritious lifestyles rooted in tribal culture.
As of June 2023, tribes directly operated 792 of the 1,008 health programs across the United States, reflecting a significant transformation in the delivery of care in Native American communities. By April 1, 2025, the Indian Health Service had formalized 118 self-governance compacts and 145 funding agreements with tribal governments and organizations across all 12 of its service areas. This growth marks a sharp contrast to the early 1990s, when barely more than a dozen tribes had entered into such agreements.
According to research conducted by the National Indian Health Board on tribally-operated healthcare centers, 86% of leaders from tribes with self-governance compacts said that they believed the quality of care had improved over the past three to four years.
The Choctaw Nation assumed full control of its health system in 1995, entering a self-governance compact under Title V of the Indian Self-Determination and Education Assistance Act. Prior to that, the system was federally operated by the Indian Health Service until 1985, then managed by the tribe through a Title I contract from 1985 to 1994.
Tribal representatives said that taking control of their health system has allowed the Choctaw Nation to expand and strengthen services across its reservation in rural southeast Oklahoma.
“Tribal health program oversight has allowed Choctaw Nation to strategically determine the best usage of funds in order to maximize health outcomes of our tribal members,” said Todd Hallmark, executive director of health for the Choctaw Nation, and Melanie Fourkiller, director of self-governance for the tribe, in a joint statement to the Daily Yonder. “The Annual Funding Agreement along with third party revenues has generated funding which has enabled our health system to grow and expand the services provided to our tribal population.”
They said that by optimizing its revenue sources, the Choctaw Nation Health Services Authority (CNHSA) has expanded clinics and specialty services while improving its ability to quickly adapt health services to meet local needs.
“The Nation can more quickly respond to local needs by designing and redesigning its health services and reallocating resources as necessary,” Hallmark and Fourkiller said. “The Nation also has more flexibility than the Indian Health Service in leveraging other resources to enhance the health system.”
Through compacting and self-governance, Hallmark and Fourkiller said the Choctaw Nation Health Services Authority is able to stretch funding further, invest in modern equipment and software, and make faster decisions to improve health care delivery.
“Utilizing the self-governance process has literally given Choctaw Nation the ability to take our health system to the next level in regard to services, quality, and, most recently, converting to a new interactive electronic medical record system, Epic, while the Indian Health Service remains burdened with an antiquated electronic health record system,” Hallmark and Fourkiller said.
CNHSA also supports both tribal members and the broader community with initiatives like free vaccinations, a rare rural residency program that hires the majority of its graduates, and housing for health care providers to address local shortages.
Church said that she is eager to facilitate the continued exercising of sovereignty by supporting other tribes in taking over management of their own health systems and building on the successes seen at Oyate Health Center.
“There’s nobody in Washington, DC, on either side of the aisle, that will do that with as much passion and commitment as our own people,” Church said. “So [I’m] looking forward to seeing more unfold around sovereignty, in taking ownership of our health care.”
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