Mission

The mission of the Indian Health Service (IHS) is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. To carry out this mission, the IHS provides comprehensive primary health care and disease prevention services. The Sanitation Facilities Construction (SFC) Program is the environmental engineering component of the IHS health delivery system. To support the IHS mission, the SFC Program provides technical and financial assistance to American Indian tribes and Alaska Native villages for the cooperative development and construction of safe drinking water supply, sewage, and solid waste disposal facilities, and related support facilities.

I. Purpose

The purpose of this report is to satisfy the reporting requirements for the Sanitation Facilities Construction (SFC) Program under section 302 of the Indian Health Care Improvement Act (IHCIA), codified as amended at 25 U.S.C. § 1632(g), excerpted below:

(g)

Annual report; sanitation deficiency levels

(1)

The Secretary shall submit to the President, for inclusion in each report required to be transmitted to the Congress under section 1671 of this title, a report which sets forth—

(A)

the current Indian sanitation facility priority system of the Service;

(B)

the methodology for determining sanitation deficiencies;

(C)

the level of sanitation deficiency for each sanitation facilities project of each Indian tribe or community;

(D)

the amount of funds necessary to raise all Indian tribes and communities to a level I sanitation deficiency; and

(E)

the amount of funds necessary to raise all Indian tribes and communities to zero sanitation deficiency.

The information in this report to Congress is used by the Indian Health Service (IHS) to establish budgetary funding requests and to allocate funding resources received. Additionally, the United States (U.S.) Environmental Protection Agency (EPA), the U.S. Department of Agriculture Rural Development, and the U.S. Department of the Interior’s Bureau of Reclamation utilize the information contained in this report to aid in the implementation of their programs that support tribal water, sewer, and solid waste infrastructure.

II. Background

The Indian Sanitation Facilities Act, Public Law (P.L.) 86-121, codified at 42 U.S.C. § 2004a, provides the SFC Program with the authority to deliver essential water supply, sewage, and solid waste disposal facilities for American Indian and Alaska Native (AI/AN) homes and communities. The IHS SFC Program is the lead federal agency for the provision of these facilities and services. Sanitation facilities are provided at the request of federally recognized tribes, bands, villages, and/or groups for homes owned and occupied by American Indians and Alaska Natives who are eligible for assistance.

Water, sewer, and solid waste sanitation deficiencies included in this report are identified solely for eligible Indian tribes and communities. Deficiencies for commercial and industrial facilities and non-Indian homes cannot be addressed by the IHS under P.L. 86-121 and are not included in this report. In addition, municipalities and communities organized under the laws of a state are not typically considered Indian communities, even though there may be eligible AI/AN people living there. The provision of community-type sanitation facilities for such non-Indian communities is generally considered to be the responsibility of the non-Indian municipality or community, and the needs are not identified by the IHS as sanitation deficiencies unless an agreement to contribute funds to cover the prorated cost of the facilities serving the non-Indian beneficiaries has been established. Under the statute, projects that include service to non-Indians must be primarily for the benefit of Indians.

III. Key Definitions

The following are key definitions used by the IHS when identifying and reporting on sanitation deficiencies:

Sanitation Deficiency

is defined as a need arising from existing water, sewer, or solid waste infrastructure (or the lack thereof) that creates or may result in exposure to environmental conditions that can negatively impact public health. IHS staff works closely with tribal officials to identify sanitation deficiencies and develop projects to address them. For reporting purposes, projects are quantified in terms of the number of projects or project phases, the estimated costs, and the number of homes requiring different types of assistance (water, sewer, solid waste, and operations and maintenance (O&M) equipment and training).

Adequate or Adequacy

implies that the sanitation facilities serving an eligible AI/AN home comply with all applicable federal, state, and local health and environmental laws and regulations and good public health practices. Adequacy also implies that eligible AI/AN homes have piped indoor water and sewer facilities.

Feasible or feasibility

implies the economic practicality of constructing the project. Projects that are determined to be economically infeasible are reported as part of the Total Database need, but are not eligible for IHS funding. Funds contributed from other entities can still be used to fund these types of projects.

Health Impact

represents the potential for occurrence of a disease or other adverse human health effect directly attributable to the failure or lack of water, sewer, or solid waste facilities. A health hazard is a water, sewer, or solid waste condition that could adversely impact human health. Health impacts and health hazards can vary for different deficiency levels.

Deficiency Level

is a numeric categorization of the magnitude of the sanitation deficiency of the facilities in question. The numeric categories are provided under section 302 of the IHCIA, codified as amended at 25 U.S.C. § 1632(g)(4), as follows:

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Level I:	An Indian tribe or community with a sanitation system which complies with all applicable water supply and pollution control laws, and in which the deficiencies relate to routine replacement, repair, or maintenance needs.
Level II:	An Indian tribe or community with a sanitation system which complies with all applicable water supply and pollution control laws, and in which the deficiencies relate to capital improvements that are necessary to improve the facilities in order to meet the needs of such tribe or community for domestic sanitation facilities.
Level III:	An Indian tribe or community with a sanitation system which has an inadequate or partial water supply and a sewage disposal facility that does not comply with applicable water supply and pollution control laws, or that has no solid waste disposal facility.
Level IV:	An Indian tribe or community with a sanitation system which lacks either a safe water supply system or a sewage disposal system.
Level V:	An Indian tribe or community that lacks a safe water supply and a sewage disposal system.

IV. Methodology

IHS field-level staff work collaboratively with tribes to identify sanitation deficiencies and plan and develop projects to address those deficiencies. IHS field-level staff are ideally positioned to complete this work because of their technical training and the relationships they build with the tribal communities they serve. Methods for identifying sanitation deficiencies include the following:

• Field visits by engineers, environmental health officers, community health representatives, nurses, or other IHS or tribal health staff;
• Sanitary surveys;
• Community environmental health profiles;
• Tribal master plans for development;
• Feasibility studies; and
• Geographic Information System (GIS) databases/maps/imagery.

Projects are developed and planned to correct the identified deficiencies. Each IHS Area incorporates tribal and community preferences, as appropriate, when identifying deficiencies and developing projects. Project planning includes the following activities:

1. Identifying AI/AN homes with sanitation deficiencies;
2. Considering applicable laws and regulations (e.g., Safe Drinking Water Act, Clean Water Act, Resource Conservation and Recovery Act);
3. Selecting the category and type of facilities needed (water, sewer, solid waste disposal, O&M development) and evaluating alternatives;
4. Identifying and mitigating risks to project implementation, such as those associated with technical design, rights-of-way, and environmental concerns;
5. Reviewing O&M considerations; and
6. Developing an engineering cost estimate (within 10 percent for high-priority projects and within 25 percent for other projects).

IHS staff, in collaboration with tribes, establish a project’s deficiency level (DL) by assessing the lack of, or condition of, existing sanitation facilities serving AI/AN homes. Projects may address a variety of sanitation deficiencies within a particular tribal community. Each proposed project or project phase will not necessarily bring all of the facilities for a tribe or community to Level 1 deficiency or better. However, the combination of all projects for a particular community will bring that community to DL 1 or better.

Developed projects are entered into the IHS Sanitation Deficiency System (SDS), a database shared by all 12 IHS Areas, where each IHS Area ranks and orders the proposed projects according to a shared methodology. Under this methodology, points are assigned for each of the following categories:

1. Health Impact (0 to 30 points) - Represents the potential for occurrence of a disease or other adverse human health effect directly attributable to the failure of (or lack of) water, sewer, or solid waste disposal facilities.
2. Project Deficiency Level (0 to 18 points) - Reflects the deficiency level of facilities to be replaced or modified by the proposed project, as defined in section 302 of the IHCIA, codified as amended at 25 U.S.C. § 1632(g)(4).
3. Adequate Previous Service (0 to 4 points) - Allows for prioritizing projects that serve communities that have not previously been provided adequate water and sewage facilities through federal sources (optional category per the Area’s guidelines).
4. Capital Cost (−20 to 16 points) - Reflects the relative cost per home served by the project compared to similar projects in the Area. Projects with a lower cost per home served receive a higher priority.
5. O&M Capability (0 to 16 points) - Reflects the probability that adequate operation and maintenance of the facilities that will be provided through the project.
6. Contributions (0 to 8 points) - Allows for prioritization of projects that leverage funding contributions from non-IHS sources (optional category per the Area’s guidelines).
7. Local Tribal Priority (0 to 16 points) - Reflects a tribe’s documented priorities for their preferred projects.
8. Local Conditions Factor (−15 to 0 points) - Allows for adjustment of the project’s overall score to compensate for unusual circumstances, such as project sequencing needs and the status of project planning (documentation by the IHS Area is required).

Each IHS Area considers a range of factors in establishing the point values assigned for each category. National guidelines have been developed to help ensure consistent project scoring. Included in these guidelines are detailed instructions on assigning deficiency levels. The SDS was developed with the intention of identifying and reporting on the projects required to raise all AI/AN homes and communities to a Level 1 sanitation deficiency (adequate water supply, sanitary sewage, and solid waste disposal facilities) or better as required by the IHCIA.

On an annual basis, the 12 IHS Area Offices update the project data that describe Area-identified sanitation facility needs, prioritize the resulting project list, and submit that data to IHS headquarters for review and compilation. That data forms the basis for this report.

V. Results

The results of the SDS methodology described in the previous section are summarized below. As depicted by the scaled graphic characterization in Figure 1, at the end of fiscal year (FY) 2019, there were 413,454 AI/AN homes included in the IHS Home Inventory Tracking System database, represented by Circle A. The area of Circle B is a representation of the 110,552 AI/AN homes identified as needing some form of sanitation facility improvement (classified as DL 2, 3, 4, or 5). The area of Circle C represents the 51,784 AI/AN homes without access to adequate sanitation facilities (DL 3, 4, or 5). The area of Circle D represents the 6,626 AI/AN homes without access to a safe water supply system and/or sewage disposal system (DL 4 and 5). Figure 2 breaks down these same home counts by IHS Area and Deficiency Level.

Figure 1

Universe of AI/AN Homes Requiring Sanitation Facility Improvements.

Figure 2

Number of AI/AN Homes Requiring Sanitation Facility Improvements by IHS Area.

The number of eligible AI/AN homes with sanitation deficiency levels 2 to 5 has decreased 52 percent since FY 2010. This decrease is likely attributed to the improved sanitation needs identification and justification by SFC Program staff, along with project funding to address sanitation deficiencies at eligible AI/AN homes. In FY 2014, a program-wide focus was made to ensure projects identifying sanitation facility needs included in the SDS were properly documented and scored according to program guidelines. This effort continued through FY 2019. Figure 3 shows the trends in total number of eligible AI/AN homes with sanitation deficiency levels 2 to 5 over the past 10 years.

Figure 3

Total Eligible AI/AN Homes with Sanitation Deficiency Levels 2 to 5.

The IHS SFC Program has compiled two estimates of the costs to address sanitation deficiencies at these homes:

1)

The Total Database Estimate includes all projects listed in the SDS without regard to economic feasibility, and

2)

The Feasible Project Cost Estimate, a subset of the Total Database Estimate, which includes only those projects considered economically feasible.

The appendix to this report contains the priority order listing by IHS Area of all projects in the Total Database. Projects that are not economically feasible have been indicated as such in this listing.

Capital costs, O&M costs, and O&M capability are evaluated as part of project planning and the priority scoring process. The feasible project cost estimate forms the basis for the IHS Funding Plan, which is used for developing budget requests and for allocating appropriated funds to the 12 IHS Areas.

Projects with high capital costs on a per-home basis are considered infeasible and are not considered when allocating appropriated funds to the Areas by IHS headquarters. All projects are re-evaluated annually to determine whether the costs and priority scoring factors have changed. In FY 2019, the Total Database of Agency-identified sanitation deficiencies included 1,563 projects. Of this total, 1,088 projects were feasible and 475 projects were infeasible with a combined Total Database cost estimated at $2.57 billion. Below displays the project cost information summarized by deficiency level (Figure 4) and type of service (Figure 5).

Figure 4

Estimated Cost to Address Sanitation Deficiencies by Deficiency Level.

Figure 5

Estimated Cost to Address Sanitation Deficiencies by Type of Service.

At the end of FY 2019, the Total Database Cost to raise all Indian tribes and communities to the DL 1 classification was estimated at $2.56 billion. Figure 6 shows the Total Database Cost broken down by IHS Area.

Figure 6

Total Database Cost to Raise Indian Tribes and Communities to a Deficiency Level 1.

At the end of FY 2019, the SDS data included $18 million in projects to raise Indian tribes and communities from a DL 1 to a DL 0. The DL 0 indicates that sanitation facilities are adequate, and all routine O&M needs have been addressed. However, given the limited SFC Program staff resources available, this need has not been fully captured in SDS and this estimate is understated. The SFC Program is currently undertaking an effort to estimate the cost of O&M needs through a less resource-intensive statistical model.

Costs for providing piped water and sewer facilities to AI/AN homes located in remote locations with harsh climates and unusual subsurface conditions are extremely high. The SFC Program recognizes that piped water and sewer projects for these homes are not currently economically feasible, and while these piped water and sewer projects are included in the Total Database Estimate, they are not included in the IHS Feasible Project Cost Estimate. At the end of FY 2019, the Feasible Project Cost Estimate was $866 million.

A summary of costs for FYs 2010 – 2019 is provided in Figure 7 below:

Figure 7

10-Year SDS Project Cost Estimates - FY 2010 through FY 2019.

The IHS may still support the planning, design, and construction of projects that are infeasible, typically as a result of funding contributions from other federal agencies and/or tribal sources. The SFC Program has provided and will continue to provide eligible AI/AN homes with other less costly types of sanitation facilities (e.g., offsite watering points and sewer haul systems). The SFC Program will also continue to track and estimate project costs to serve these homes with piped water and sewer systems.

The cost of the needed facilities to address all sanitation deficiencies has historically had an upward trend as shown in Figure 7. The increasing cost of addressing sanitation deficiencies reflects the effects of inflation, changes resulting from factors such as new regulations, changes in the number of eligible homes, new tribes gaining federal recognition, and the deterioration of previously installed facilities. In FY 2019, the total cost of sanitation facilities to address all needs in Indian Country decreased by $93 million over the FY 2018 level. Program staff will continue to work with their tribal counterparts to improve the reporting of sanitation deficiencies, which may contribute to fluctuations in the total cost estimate in future years.

VI. Appendix

{See attached PDF FY 2019 Annual Report of Sanitation Deficiency Levels}

IHS Area - Alaska (AN) (PDF, 405K)

IHS Area - Albuquerque (AL) (PDF, 206K)

IHS Area - Bemidji (BE) (PDF, 191K)

IHS Area - Billings (BI) (PDF, 136K)

IHS Area - California (CA) (PDF, 208K)

IHS Area - Great Plains (GP) (PDF, 291K)

IHS Area - Navajo (NA) (PDF, 514K)

IHS Area - Nashville (NA) (PDF, 104K)

IHS Area - Oklahoma City (OK) (PDF, 330K)

IHS Area - Phoenix (PH) (PDF, 225K)

IHS Area - Portland (PO) (PDF, 121K)

IHS Area - Tucson (TU) (PDF, 124K)

In accordance with The Indian Health Care Improvement Act P.L. 94-437, as amended 25 U.S.C. § 1601 et seq.