Detailed Information on the
Maternal and Child Health Block Grant Assessment

Conduct program evaluation

Conduct evaluation of the effects of Title V Block Grant infrastructure investments.

Measure: National rate of maternal deaths per 100,000 live births

Explanation:

Measure: National rate of infant deaths per 1,000 live births

Explanation:

Measure: National rate of illness and complications due to pregnancy per 100 deliveries

Explanation:

Measure: National rate of illness and complications due to pregnancy per 100 deliveries

Explanation:

Measure: Reduce neonatal deaths to 4.5 per 1,000 live births by 2008.

Explanation:

Measure: Decrease the number of uninsured children to 8 million by 2008.

Explanation:

Measure: Reduce the incidence of low birth weight births.

Explanation:

Measure: Increase the number of children receiving Title V services who enroll in and have Medicaid and SCHIP coverage.

Explanation:

Measure: Increase the percent of low birth weight babies who are delivered at facilities for high-rsk deliveries and neonates.

Explanation:

Is the program purpose clear?

Explanation: The purpose and mission of the MCH Block Grant is to improve the health of all mothers, children, and their families by: 1) assuring access to quality care, 2) reducing infant mortality and the incidence of preventable diseases, 3) providing prenatal and postnatal care to women, 4) increasing the number of children receiving health assessments, 5) implementing community-based, family-centered care for children with special health care needs, and 6) providing assistance to mothers for services.

Evidence: Title V of the Social Security Act authorizes this program and clearly states the purpose of the program. In addition, the mission of the MCH Block Grant is included in the HRSA and MCH Bureau Strategic Plans, as well as the Congressional Justification.

Does the program address a specific interest, problem or need?

Explanation: The MCH Block Grant is a safety net program for low-income, at risk pregnant women; children with special health care needs; the uninsured; and the underinsured. Nearly 12 percent of all children were uninsured in 2000, thus causing increased demand for MCH Block Grant services. In addition, disparities in health indicators often leads to MCH Block Grant funds being used to address health disparities in certain underserved communities.

Evidence: HRSA FY 2003 Congressional Justification and GPRA Plan.

Is the program designed to have a significant impact in addressing the interest, problem or need?

Explanation: The MCH Block Grant is the payer of last resort. It is the only Federal program that focuses on improving the health of all mothers and children, in particular assisting the underinsured and uninsured. The MCH Block Grant operates in partnership with State MCH and Children with Special Health Care Needs programs.

Evidence: Title V of the Social Security Act requires $3 of every $4 Federal dollars to be matched by states (www.mchdata.net).

Is the program designed to make a unique contribution in addressing the interest, problem or need (i.e., not needlessly redundant of any other Federal, state, local or private efforts)?

Explanation: Activities funded under the MCH Block Grant tend to work in tandem with other similar efforts. Without these resources and the required state match, there would be a substantial decrease in available resources and systems to care for vulnerable populations. This, in effect, would likely cause: 1) increases in infant mortality, 2) increases in the incidence of preventable handicapping conditions among these populations, and 3) decreased children appropriately immunized.

Evidence: Between 1995 and 2000, the number of children served by Title V increased from 20.2 million to 22.8 million, the percentage of children with special health care needs with a source of insurance for primary and specialty care increased from 83 percent to 90.3 percent, and the percent of infants born to pregnant women who received prenatal care beginning in the first trimester increased from 82.5 percent to 83.2 percent.

Is the program optimally designed to address the interest, problem or need?

Explanation: The MCH Block Grant is intended to provide funding to states to strengthen their public health infrastructure and to address service delivery gaps for women and children that are not addressed by any other public or private program. The current formula takes into consideration the number of low-income children in a state in proportion to the number of low-income children in the nation. In addition, the program is designed to be a partnership in which the state also has a significant stake in providing for the services of mothers and children (3 of every 4 Federal dollars are matched by states.)

Evidence: Title V of the Social Security Act.

Does the program have a limited number of specific, ambitious long-term performance goals that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: HRSA's Maternal and Child Health Bureau (MCHB) has developed its own 5-year strategic plan, which provides 3 goals and 27 specific objectives that focus on eliminating barriers and health disparities, assuring quality of care, and improving health infrastructure (states report on 18 nationally uniform targeted measures). MCH performance goals are also included in Healthy People 2010 and supported by HRSA. MCHB activities are also addressed in HRSA's 5-year plan. In addition, OMB and HRSA/MCHB recently developed ambitious long-term outcome goals that link to the mission of the program. Baseline data are available for all new measures.

Evidence: HRSA/MCHB's newly developed long-term outcome goals are: 1) Increase maternal survival to 8 maternal deaths per 100,000 live births by 2008, 2) Reduce infant deaths to 6.5 per 1,000 live births by 2008, 3) Decrease the number of uninsured children to 8 million by 2008, and 4) Reduce neonatal deaths to 4.5 per 1,000 live births by improving the quality of prenatal care by 2008.

Does the program have a limited number of annual performance goals that demonstrate progress toward achieving the long-term goals?

Explanation: HRSA's GPRA plan includes annual goals. OMB and HRSA/MCHB recently developed discrete, quantifiable, and measurable annual performance goals that demonstrate progress toward achieving the long-term goals established.

Evidence: A few of HRSA/MCHB's newly developed annual goals are: 1) Reduce illness and complication due to pregnancy to 26 per 100 deliveries, 2) Reduce the incidence of low-birth weight to 7.3 percent, 3) Increase the number of children receiving Title V services who enroll in and have Medicaid and SCHIP coverage to 7 million, and 4) Increase to 85 percent low birth weight babies who are delivered at facilities for high-risk deliveries and neonates.

Do all partners (grantees, sub-grantees, contractors, etc.) support program planning efforts by committing to the annual and/or long-term goals of the program?

Explanation: In 1997, MCHB gained States' support and commitment to reporting requirements developed in collaborative efforts with States to identify performance measures and data that would support the goals of the program. Every State sets target values for each of 18 measures for a five-year period and reports annually on actual performance. The data contained in the annual report and application submitted each July, report achievements and set targets for the upcoming fiscal year.

Evidence: 1) Title V Information System. 2) www.mchdata.net.

Does the program collaborate and coordinate effectively with related programs that share similar goals and objectives?

Explanation: No other programs in the Federal government share all of the goals and objectives of the MCH Block Grant; however, the program coordinates broadly with programs that share one or more of its goals and objectives. Primary partnerships are with State MCH and Children with Special Health Care Needs programs. MCHB has also forged partnerships with 275 organizations and programs, including national public and private organizations, state and local governments. In addition, States match $3 of every $4 Federal dollars provided, which leverages $2.3 billion from States. MCHB also has partnerships with CMS to encourage Medicaid eligible children to apply for SCHIP.

Evidence:  

Are independent and quality evaluations of sufficient scope conducted on a regular basis or as needed to fill gaps in performance information to support program improvements and evaluate effectiveness?

Explanation: Independent and quality evaluations of the MCH Block Grant or its large subparts (CISS and SPRANS) do not regularly occur, even to fill gaps in performance evaluation. The scope of the numerous evaluations that occur each year by academic researchers, state Department's of Public Health, and other institutions is insufficient to assess the Block Grant. The evaluations are of state-specific, local-level activities funded with Title V resources. As a result it is difficult to assess the impacts of the overall MCH Block Grant.

Evidence: 1) Virginia Resource Mothers Program, 2001 Annual Report. 2) National Center for Children, Families and Communities. 3) Texas Department of Public Health, March 2001.

Is the program budget aligned with the program goals in such a way that the impact of funding, policy, and legislative changes on performance is readily known?

Explanation: HRSA's OMB budget justification and Congressional justification display the line item for the MCH Block Grant. However, when HRSA submits its budget request to the Department for review, the annual targets are adjusted according to the funding level requested and/or the final funding level provided by the Department, not based on estimates generated from a model/mechanism in place that allows for cost per unit of service/marginal dollar change projections. HRSA has made improvements in its internal control system by integrating planning and budgeting and developing annual targets associated with the program activity; however, HRSA has not yet moved to being able to make budget decisions using a more precise and detailed system of costing that is also linked to adjusting targets to achieve the established long-term and annual performance goals.

Evidence: 1) OMB Budget Justification submitted each Fall. 2) Congressional Justification submitted each February with the President's Budget.

Has the program taken meaningful steps to address its strategic planning deficiencies?

Explanation: Current evaluation efforts include bi-annual audits, annual reviews and 5 year State needs assessments and national surveys. HRSA is working on a customer satisfaction survey. In addition, each year input is sought from states on the planning for strategic management of the universal goals that are reported by all states.

Evidence:  

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: HRSA regularly collects data through its automated Title V Electronic Reporting Package. This information is used by internal and external experts to review each State's performance and budget data based on previous projections and future plans. Teams meet with each State to review their performance plans. States provide additional information to correct necessary data. Information is shared publicly on the MCHB's website so that States may assess their progress with other States and use this information to manage better.

Evidence: www.mchdata.net

Are Federal managers and program partners (grantees, subgrantees, contractors, etc.) held accountable for cost, schedule and performance results?

Explanation: The Federal managers of the MCH Block Grant negotiated with States to develop a national set of 18 performance measures to increase States' accountability. Some of these core measures are included in the MCHB Associate Administrator's individual performance contract. States are also encouraged to develop special State-specific measures that address their own priority needs.

Evidence: www.mchdata.net

Are all funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: HRSA/MCHB has obligated its funding by quarter fairly consistently over the years. Funds are obligated nearly evenly across all four quarters. Financial status reports show minimal unobligated balances. MCHB monitors grantee expenditures to ensure compliance with legislation, regulation and policies.

Evidence: 1) Estimated obligations by quarter in apportionments for FYs 1999-2001. 2) Actual obligations by quarter for FYs 1999-2001. NOTE: All grantees expending above $300,000 in Federal funds provide Single Audit Act reports.

Does the program have incentives and procedures (e.g., competitive sourcing/cost comparisons, IT improvements) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The MCHB is in the process of implementing several IT improvements, including a web-based application for the MCH Block Grant to become effective during the FY 2003 reporting cycle. It is expected that this process will reduce the time and effort needed for States to prepare and submit their Block Grant Application and Annual Report and ensure that MCHB can post data provided within the first quarter of the new fiscal year.

Evidence: 1) Title V Electronic Reporting Package. 2) www.mchdata.net.

Does the agency estimate and budget for the full annual costs of operating the program (including all administrative costs and allocated overhead) so that program performance changes are identified with changes in funding levels?

Explanation: The program's annual budget requests are not derived in such a way that HRSA is able to track the full annual costs associated with achieving long-term or annual goals. HRSA's current methodology is to request and track most programs' administrative and overhead costs in a Program Management line item and then allocate these resources to the program. Program staff do not have a model/mechanism in place for determining overhead on a per unit basis nor are they able to integrate program costs with the costs necessary to achieve the long-term and annual goals. Like most other agencies across government, HRSA develops its budget using the reverse methodology. HRSA identifies the funding level, then increases or decreases its annual targets according to the funding level proposed.

Evidence: 1) Estimated obligations by quarter in apportionments for FYs 1999-2002. 2) Actual obligations by quarter for FYs 1999-2002.

Does the program use strong financial management practices?

Explanation: HRSA financial statements are conducted by the Program Support Center. Staff reviewed financial reports within a five year time frame for which there was an internal control material weakness identified for MCH activities in 2000. The FY 2000 Annual Report includes the following statement regarding fluctuations in net cost for the year, "Maternal and Child Health costs decreased by twenty-two percent ..., over amounts reported in its fiscal 1999 financial statements. Management could not initially provide explanations for these fluctuations, which indicates a lack of complete understanding of the operating results reflected in HRSA's accrual [based] financial statements...".

Evidence: FY 1997-2001 HRSA Annual Reports.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: Each year financial management deficiencies are corrected. HHS is developing a financial system to better track overall financial management across the Department.

Evidence:  

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: The MCHB uses grant applications, face-to-face reviews of State plans and annual reports, bi-weekly conference calls with regional office staff, special subject matter meetings, technical assistance, and site visits by regional staff to monitor grantee activities.

Evidence:  

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: Data are collected from grantees and are published each calendar year and made available to grantees and the public on the MCHB website. Hard copies of state data are also available.

Evidence: 1) Title V - A Snapshot of Maternal and Child Health. 2).www.mchdata.net/Reports_Graphs/finmenu.htm.

Has the program demonstrated adequate progress in achieving its long-term outcome goal(s)?

Explanation: The MCH Block Grant has contributed to the overall decline in the number of babies born with low birth weight and the rate of infant mortality. The Block Grant has also increased the number of uninsured children receiving access to care and has played an important part in the overall health outcomes of mothers and children. State MCH agencies have made significant progress in realizing long-term MCHB goals.

Evidence: www.mchdata.net/Reports_Graphs/finmenu.htm.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The MCH Block Grant has enhanced access to care for many mothers and children. Overall, the Block Grant and State partners have been achieving their annual performance goals. However, in the case of the ambitious goal to reduce the incidence of low birth weight births, most States have not achieved their targets. Increases in number of multiple births and increased maternal age, as well as unknown factors have increased the incidence of low birth weight infants, despite increased efforts. This issue is being studied by outside entities to determine what action is needed to improve the outcome.

Evidence:  

Does the program demonstrate improved efficiencies and cost effectiveness in achieving program goals each year?

Explanation: The MCH Block Grant demonstrates cost effectiveness. The MCH Block Grant's contribution to these activities has remained relatively flat, yet goals are being met and health outcomes are improving.

Evidence:  

Does the performance of this program compare favorably to other programs with similar purpose and goals?

Explanation:  

Evidence:  

Do independent and quality evaluations of this program indicate that the program is effective and achieving results?

Explanation: Many of the 59 States and Territories that receive MCH Block Grant funds have had academic researchers, state Department's of Public Health, and other institutions evaluate the performance of specific activities funded under the Block Grant. These limited in scope evaluations have shown that local level activities funded by the MCH Block Grant achieve results. However, because independent and quality evaluations of the MCH Block Grant as a whole or even in large subparts (CISS or SPRANS) are not conducted, full credit can not be provided.

Evidence: A 2001 Annual Report by Virginia Resource Mothers Program addressed the rate of low-birth weight babies for those teens receiving services from a program funded with Title V resources compared to nonparticipating teens. Those teens that are not participating in interventions funded with Title V resources have had higher rates of birthing children with low birth rates.