Food Assistance: WIC Faces Challenges in Providing Nutrition	 
Services (07-DEC-01, GAO-02-142).				 
								 
The Special Supplemental Nutrition Program for Women, Infants,	 
and Children (WIC) serves almost half of all infants and about	 
one-quarter of all children between one and four years of age in 
the United States. The WIC program faces the following challenges
in delivering high quality nutrition services: (1) coordinating  
its nutrition services with health and welfare programs 	 
undergoing considerable change, (2) responding to health and	 
demographic changes in the low-income population that it serves, 
(3) recruiting and keeping a skilled staff, (4) improving the use
of information technology to enhance service delivery and program
management, (5) assessing the effect of nutrition services, and  
(6) meeting increased program requirements without a		 
corresponding increase in funding. GAO identified 16 approaches  
to address the major challenges facing the program. Although each
of the approaches offers certain advantages, they also have	 
potential negative consequences that policymakers should	 
consider.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-142 					        
    ACCNO:   A02442						        
  TITLE:     Food Assistance: WIC Faces Challenges in Providing       
Nutrition Services						 
     DATE:   12/07/2001 
  SUBJECT:   Food programs for children 			 
	     Information technology				 
	     Program evaluation 				 
	     Disadvantaged persons				 
	     Personnel recruiting				 
	     Labor force					 
	     Cost control					 
	     Grant monitoring					 
	     CDC Pediatric Nutrition Surveillance		 
	     System						 
								 
	     CDC Pregnancy Nutrition Surveillance		 
	     System						 
								 
	     Food Stamp Program 				 
	     HHS Temporary Assistance for Needy 		 
	     Families Program					 
								 
	     Maternal and Child Health Services Block		 
	     Grant						 
								 
	     Medicaid Program					 
	     Special Supplemental Nutrition Program		 
	     for Women, Infants and Children			 
								 

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GAO-02-142
     
Report to Congressional Committees

United States General Accounting Office

GAO

December 2001 FOOD ASSISTANCE WIC Faces Challenges in Providing Nutrition
Services

GAO- 02- 142

Page i GAO- 02- 142 WIC Challenges Letter 1

Results in Brief 3 Background 3 WIC Faces Challenges in Delivering High-
Quality Nutrition

Services 6 Approaches to Addressing WIC Challenges 37 Conclusions 39
Recommendations for Executive Action 39 Agency Comments and Our Response 40

Appendix I Stakeholders Providing Comments on Proposed Approaches for
Overcoming Challenges Facing WIC 41

Appendix II Program Tasks Identified by USDA 43

Appendix III Approaches to Overcoming Challenges Facing WIC 45

Appendix IV GAO Contacts and Staff Acknowledgments 64 GAO Contacts 64 Staff
Acknowledgments 64

Tables

Table 1: Major New Program Requirements Since 1988 32 Table 2: Sixteen
Approaches to Addressing WIC Challenges 38 Table 3: Automated Function
Descriptions 43

Figures

Figure 1: Percentage of Medicaid Beneficiaries Enrolled in Managed Care,
1991- 2000 7 Figure 2: Percentage of WIC Expenditures for NSA - Including
and

Excluding Rebate Funds, Fiscal Years 1988- 1999 35 Contents

Page ii GAO- 02- 142 WIC Challenges Abbreviations

CDC Centers for Disease Control and Prevention EBT electronic benefits
transfer FNS Food and Nutrition Service HHS Department of Health and Human
Services NAWD National Association of WIC Directors NSA Nutrition Services
and Administration PC Participant and Program Characteristics PedNSS
Pediatric Nutrition Surveillance System PNSS Pregnancy Nutrition
Surveillance System TANF Temporary Assistance for Needy Families USDA U. S.
Department of Agriculture WIC Special Supplemental Nutrition Program for
Women,

Infants and Children

Page 1 GAO- 02- 142 WIC Challenges

December 7, 2001 The Honorable Tom Harkin Chairman The Honorable Richard G.
Lugar Ranking Minority Member Committee on Agriculture, Nutrition, and
Forestry United States Senate

The Honorable John A. Boehner Chairman The Honorable George Miller Ranking
Democratic Member Committee on Education and the Workforce House of
Representatives

After nearly 30 years, the Special Supplemental Nutrition Program for Women,
Infants and Children (WIC) has become one of the nation?s most important
nutrition assistance programs, serving almost half of all infants and about
one- quarter of all children between 1 and 4 years of age in the United
States. WIC is a federally funded grant program administered by the U. S.
Department of Agriculture?s (USDA) Food and Nutrition Service (FNS). In
fiscal year 2000, WIC grants supported state- level provision of benefits to
a monthly average of about 7.2 million participants, mostly lowincome women
and children at nutritional risk, through nearly 1, 900 local agencies.

In fiscal year 2000, WIC provided about $4.1 billion to fund program
operations. Of that amount, about $3 billion was for food grants and about
$1.1 billion was for Nutrition Services and Administration (NSA) grants.
Food grants cover the cost of supplemental foods; typically, participants
are given paper vouchers- usually referred to as checks- to obtain approved
foods at authorized grocery stores. The nutrition services supported by NSA
grants are (1) participant services - activities such as certifying that a
woman or child is eligible to participate in the program, issuing food
benefits, and making referrals to health and social services; (2) nutrition
education - providing individual or group education designed to improve
participants? dietary habits and health status; and (3) breastfeeding
promotion and support - educating women about the benefits of breastfeeding
and providing the support necessary to enable them to breastfeed.

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 02- 142 WIC Challenges

To help the Congress better understand the costs of administering WIC and
delivering nutrition services, the William F. Goodling Child Nutrition
Reauthorization Act of 1998 (P. L. 105- 336) directed GAO to assess various
aspects of WIC?s NSA. This report (1) describes the challenges that state
and local WIC agencies face in providing nutrition services and
administering the program and (2) identifies approaches to address these
challenges. We have explored the advantages, disadvantages, and possible
consequences of the approaches whenever possible. This report is the final
in a series of reports providing the Congress with information about the WIC
program. 1

To identify the challenges facing the program and approaches that could be
used to address these challenges, we conducted a range of research. First,
we conducted a review of WIC- related literature. We also analyzed
information collected during our previous WIC work in this series, including
the results of nationwide surveys of state and local WIC agencies 2 and case
studies of six judgmentally selected WIC agencies. 3 In addition, we
analyzed historical program data provided by USDA, and we reviewed program
regulations and policies as well as various WIC- related reports. Finally,
we conducted interviews with program stakeholders, including USDA officials,
state and local WIC agency officials, representatives from the Center for
Budget and Policy Priorities, the American Enterprise Institute, and
officials from the Department of Health and Human Services, including the
Centers for Disease Control and Prevention (CDC).

1 Food Assistance: Financial Information on WIC Nutrition Services and
Administrative Costs (GAO/ RCED- 00- 66, Mar. 6, 2000); Food Assistance:
Activities and Use of Nonprogram Resources at Six WIC Agencies (GAO/ RCED-
00- 202, Sep. 29, 2000); Food Assistance: Performance Measures for Assessing
Three WIC Services (GAO/ 01- 339, Feb. 28, 2001); Food Assistance: Research
Provides Limited Information on the Effectiveness of Specific WIC Nutrition
Services (GAO- 01- 442, Mar. 30, 2001).

2 For GAO/ RCED- 00- 66, Mar. 6, 2000, we conducted nationwide surveys in
1999 of (1) 55 state- level agencies that operate in the 50 states and in
the District of Columbia, American Samoa, the Commonwealth of Puerto Rico,
Guam, and the U. S. Virgin Islands; (2) all 33 Indian tribal organizations;
and (3) 1,780 local WIC agencies. That report contains a description of the
survey methodologies.

3 For GAO/ RCED- 00- 202, Sep. 29, 2000, we conducted a case study at a
local WIC agency in each of the following five states: California, Georgia,
Minnesota, Montana, and Pennsylvania. We also conducted a sixth case study
at the WIC program sponsored by the Indian Tribal Organization of Zuni; this
state- level WIC agency provides services directly to Zuni WIC participants.
That report contains a description of the case study methodology.

Page 3 GAO- 02- 142 WIC Challenges

We provided major stakeholders with a draft of the approaches that we
identified and asked for their views regarding the advantages and
disadvantages of each approach. Appendix I provides a list of the
stakeholders who provided their views regarding the advantages and
disadvantages of the identified approaches. We conducted our work between
December 2000 and November 2001 in accordance with generally accepted
government auditing standards.

The WIC program faces the following challenges in delivering high- quality
nutrition services: (1) coordinating its nutrition services with health and
welfare programs undergoing considerable change; (2) responding to health
and demographic changes in the low- income population that it serves; (3)
recruiting and keeping a skilled staff; (4) improving the use of information
technology to enhance service delivery and program management; (5) assessing
the effect of nutrition services; and (6) meeting increased program
requirements without a corresponding increase in funding.

We identified and assessed 16 approaches that could address aspects of the
major challenges facing the program. Most of the approaches we identified
address a specific aspect of more than one of the six major challenges
facing the program. Four of the approaches focus on funding, four relate to
performance or impact measurement, three address staffing issues, three
relate to information technology, and two relate to the provision of
nutrition services. While each of the approaches offer certain advantages,
they also have potential negative consequences that policymakers should
consider.

We are making recommendations to USDA that are intended to help the agency
identify strategies to address program challenges in recruiting and
retaining a skilled staff and assessing the effects of nutrition services.
USDA officials generally agreed with the report?s findings and
recommendations.

The WIC program was created in 1972 in response to growing evidence of poor
nutrition and related health problems among low- income infants, children,
and pregnant women. It is intended to serve as an adjunct to good health
care during critical times of growth and development. In addition, WIC was
designed to supplement the Food Stamp Program and other programs that
distribute foods to needy families. Results in Brief

Background

Page 4 GAO- 02- 142 WIC Challenges

Several population groups are eligible for the supplemental foods and
nutrition services offered by WIC. Eligible groups include lower- income
pregnant women, nonbreastfeeding women up to 6 months postpartum,
breastfeeding women up to 1 year postpartum, infants, and children up to age
5 who are at nutritional risk. WIC provides cash grants to support program
operations at 88 state- level WIC agencies, including those in all 50
states, American Samoa, the District of Columbia, Guam, Puerto Rico, the U.
S. Virgin Islands, and 33 Indian tribal organizations.

Food and NSA grants are allocated to the state agencies through a formula
based on caseload, inflation, and poverty indices. Small amounts are also
set aside and distributed, at USDA?s discretion, to fund updates to
infrastructure- like the development of electronic benefit transfers- and to
fund evaluations performed by state agencies. Some state- level agencies
that operate the program at both the state and local levels retain all of
their WIC grants. The remaining state- level agencies retain a portion (the
national average is about one- quarter) of the funds for their state- level
operations and distribute the remaining funds to nearly 1,800 local WIC
agencies.

In 1998, state and local WIC agencies relied primarily on their federal NSA
grant funds to support their NSA operations. 4 Although no state- matching
requirement exists for federal WIC funding, some state WIC agencies have
received supplemental funds from their state governments for NSA. Some state
and local WIC agencies also receive in- kind contributions, such as office
space, from nonfederal sources such as local governments and private
nonprofit agencies.

NSA grants cover the costs of providing various nutrition services-
participant services, nutrition education, and breastfeeding promotion.
Participant services include numerous activities such as determining
eligibility, food benefit distribution, screening for up- to- date
immunizations, and referrals to other health or social services. Each of
these activities includes many processes. For instance, we reported in
September 2000 that certification involves identifying income, participation
in a qualifying program such as Medicaid, pregnancy or

4 See Food Assistance: Financial Information on WIC Nutrition Services and
Administrative Costs (GAO/ RCED- 00- 66, Mar. 6, 2000). WIC Agencies Rely

Primarily on Federal Funding to Provide Nutrition Services

NSA Grants Support Several Services Provided to WIC Participants

Page 5 GAO- 02- 142 WIC Challenges

postpartum status, and medical or nutritional risks. The length of time that
a person is certified to participate in the program typically ranges from 6
months to 1 year, depending on such factors as whether the participant is a
woman, a child, or an infant.

Nutrition education consists of individual or group education sessions and
the provision of information and educational materials to WIC participants.
Regulations require that the nutrition education bear a practical
relationship to participant nutritional needs, household situations, and
cultural preferences. Nutrition education is offered to all adult
participants and to parents and guardians of infant or child participants,
as well as child participants, whenever possible. It may be provided through
the local agencies directly or through arrangements made with other
agencies. Individual participants are not required to attend or participate
in nutrition education activities to receive food benefits.

Breastfeeding promotion activities focus on encouraging women to breastfeed
and supporting those women who choose to breastfeed. Each local agency is
required to designate a breastfeeding coordinator, and new staff members are
required to receive training on breastfeeding promotion and support. WIC
endorses breastfeeding as the preferred method of infant feeding.

Although state agencies must operate within the bounds of federal
guidelines, they have the flexibility to adjust program services to meet
local needs. States can add program requirements. For example, in 1999,
Montana required its local agencies to formally document referrals made to
WIC participants, though this is not required by program regulation. States
that utilize local agencies to provide nutrition services also provide these
local agencies with some discretion in implementing the local program. This
means that the specifics of the WIC program can vary from state to state and
locality to locality. In 2001, USDA and the National Association of WIC
Directors (NAWD) distributed revised Nutrition Service Standards that
provide WIC agencies with guidelines on providing high- quality nutrition
services.

Page 6 GAO- 02- 142 WIC Challenges

The WIC program faces the following challenges in delivering high- quality
nutrition services: (1) coordinating its nutrition services with health and
welfare programs undergoing considerable change; (2) responding to health
and demographic changes in the low- income population that it serves; (3)
recruiting and keeping a skilled staff; (4) improving the use of information
technology to enhance service delivery and program management; (5) assessing
the effect of nutrition services; and (6) meeting the increased program
requirements without a corresponding increase in funding.

Over the past decade, major changes in the nation?s health and welfare
delivery systems have presented WIC agencies with the challenge of
identifying and enrolling eligible participants and coordinating with other
service providers in a new environment. More specifically, state Medicaid
agencies? increased reliance on private managed care organizations has
reduced the service delivery role of local public health agencies, the
entities with which WIC agencies have had a long- established relationship.
As a result, WIC?s link to the health care system has been weakened, making
it more difficult for WIC agencies to identify eligible individuals and
coordinate services with their participants? health care providers.
Additionally, changes brought about by welfare reform- which include the
elimination of Temporary Assistance for Needy Families (TANF), Food Stamp,
and Medicaid benefits for many individuals including noncitizens- have
decreased WIC?s ability to reach eligible individuals through these
programs.

Two recent and related changes in the health care system are presenting new
challenges to WIC agencies in carrying out their referral, outreach, and
coordination efforts. The first change is the rapid growth since 1991 in the
percentage of Medicaid beneficiaries who are enrolled in managed care (see
fig. 1). WIC Faces Challenges

in Delivering HighQuality Nutrition Services

The Challenge of Adapting to Recent Changes in the Health and Welfare
Delivery System

Health Care System Changes Make It More Difficult for WIC to Serve as an
Adjunct to Health Care

Page 7 GAO- 02- 142 WIC Challenges

Figure 1: Percentage of Medicaid Beneficiaries Enrolled in Managed Care,
1991- 2000

Source: Health Care Financing Administration, Department of Health and Human
Services, 2001.

This increase in the percentage of Medicaid beneficiaries receiving health
services from managed care providers contributed, in part, to the second
change: the reduction or elimination of direct health care services by many
local public health departments. According to a national survey of local
health departments offering comprehensive primary care services in urban
areas in 1995, about 20 percent stopped providing such services to women and
children by 1999. 5 Similarly, about 9.4 percent of those offering
comprehensive primary care services to women in nonurban areas in 1995
stopped providing such services by 1999, and 15.5 percent of nonurban
agencies stopped providing such services to children.

With the reduction in the number of public health departments serving women
and children, public health officials have increasingly turned to WIC to
help address the health needs of low- income children. According to CDC, WIC
has become the single largest point of access to health

5 Institute of Medicine, America?s Health Care Safety Net, National Academy
Press: Washington, D. C., 2000.

Page 8 GAO- 02- 142 WIC Challenges

related services for low- income preschool children. Consequently, the CDC
has turned to WIC to provide services traditionally performed by local
health departments, such as identifying children who are not fully
immunized.

These changes have several implications for WIC. Historically, many WIC
participants have been able to receive health services, such as pediatric
care, at the WIC sites. This proximity could facilitate the required link
between WIC services and health care; health care providers could easily
refer Medicaid and uninsured patients to the WIC program, and WIC staff
could easily refer WIC participants to appropriate health care services.
This arrangement also made it more convenient for participants to schedule
appointments for both WIC and health services. However, as Medicaid managed
care providers have increasingly replaced local public health clinics as
providers of maternal and child health care, this link between WIC services
and health care has weakened. The convenience for many WIC staff and
participants of having WIC and health care services co- located has been
lost. As a result, many WIC agencies must extend their outreach efforts to
contact people, especially uninsured individuals not connected with the
health care system, who are eligible for WIC.

Given these changes, it will be a challenge for WIC to effectively
coordinate its services with other health providers. Evidence already
suggests that WIC agencies are struggling with this coordination. For
example, a national survey conducted by the Women?s and Children?s Center at
Emory University?s Rollins School of Public Health found that only 26
percent of state WIC agencies had made specific arrangements, such as
developing formal guidance, for the collaboration of services between WIC
and managed care providers in 2000. The Center published a resource guide to
assist in the collaboration between WIC and managed health care. 6 The guide
identified several barriers to the coordination between WIC and managed care
providers and provided descriptions of strategies that state and local WIC
agencies can use to overcome such barriers, though it suggests that
employing suggested strategies will increase staff responsibility and
program costs. The barriers include the following:

6 Bell, Karen N., Collaboration between WIC and Managed Care: a Resource
Guide,

Women?s and Children?s Center, Rollins School of Public Health (GA, May
2001) (http// www. sph. emory. edu/ wcc/ wicmc/).

Page 9 GAO- 02- 142 WIC Challenges

 Lack of understanding. WIC staff do not understand the managed care system
and managed care providers do not understand WIC.

 Lack of specific requirements. State Medicaid agencies may not have
instituted specific contractual requirements for managed care organizations
or providers to make referrals or supply needed information to WIC agencies.

 Communication difficulties. Managed care providers? change in ownership
has been accompanied by communication difficulties. The termination of
Medicaid contracts with managed care providers and the location of some
managed care provider headquarters in another state can also make
communication difficult.

Welfare reform, which made major changes to the nation?s social safety net,
has also placed new demands on WIC?s client services and outreach. The
Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.
L. 104- 193), which replaced the Aid to Families with Dependent Children
with TANF, established a lifetime, 5- year time limit on the receipt of TANF
benefits and required states to place work or work- related requirements on
a percentage of households receiving TANF. The act also made several
categories of noncitizens ineligible for TANF, food stamps, and Medicaid.

Welfare reform has contributed to the decline in the participation in public
assistance programs. Various studies, including those that we have
conducted, have concluded that the implementation of the provisions of
welfare reform is associated with the decline of eligible individuals
enrolled in the Food Stamp Program and Medicaid. Although we did not
identify any nationwide assessment of welfare reform?s impact on WIC
participation, state and/ or local WIC officials from all six of our case
study agencies reported that welfare reform has decreased program
participation by eligible individuals, including noncitizens and working
women.

Declining participation in assistance programs may complicate WIC client
services, such as making eligibility and referral determinations.
Individuals who receive TANF, food stamps, or Medicaid automatically meet
WIC?s income eligibility requirement- documentation of their enrollment in
one or all of these programs is sufficient proof that they qualify
financially for WIC. However, as the number of WIC applicants who are
enrolled in these programs decreases, WIC staff members may need to spend
more time collecting and reviewing other documents to determine whether
applicants meet income eligibility requirements. Moreover, the
responsibility of WIC staff to make appropriate referrals to other Welfare
Reform Has Increased

Demands on WIC Outreach and Coordination

Page 10 GAO- 02- 142 WIC Challenges

programs, both public and private, may grow at those agencies where WIC has
become a gateway to the social safety net for low- income individuals.

Restrictions on providing welfare benefits to noncitizens may require WIC to
increase its outreach efforts among these groups. With welfare reform,
several categories of noncitizens are no longer eligible for TANF, food
stamps, or Medicaid. However, noncitizens continue to be eligible for the
WIC program. The National Advisory Council on Maternal, Infant and Fetal
Nutrition, as well as WIC officials from several of our case studies,
suggested that noncitizens may fear that participating in WIC could threaten
their immigration status.

Welfare reform?s emphasis on work has created the challenge of making WIC
services accessible to a population with new demands on their time. In five
of our six case study sites, WIC officials attributed declines in WIC
participation, in part, to the increase in the number of women who were
working or attending school due to welfare reform. At three case study
sites, WIC officials indicated that the increasing numbers of working women
placed increased pressure on WIC agencies to offer WIC services outside of
normal working hours. Increasing access, which may involve offering evening
or weekend hours, can result in higher costs to the WIC program.

WIC faces the challenge of responding to changes in the health and
demographics of its participants and potential participants. The WIC
population, like the general population, has experienced a dramatic increase
in the prevalence of overweight and obesity and related diseases, such as
diabetes. In addition, demographic changes, such as increases in WIC?s
ethnic population, have occurred during recent years. These changes have
placed demands on WIC agencies to play a more active role in helping to
treat and prevent nutrition- related health problems and adapting nutrition
services to the evolving needs of program participants. The Challenge of

Responding to New Health Concerns and Demographic Changes

Page 11 GAO- 02- 142 WIC Challenges

The nation?s population has experienced a dramatic increase in the
prevalence of overweight and obesity in recent years. 7 According to the
CDC, the prevalence of overweight and obesity has reached epidemic
proportions. For example, the prevalence of overweight adults increased over
60 percent between 1991 and 2000. Research suggests that the prevalence of
overweight and obesity is even higher among individuals who are low- income,
a characteristic of the WIC population.

The surge in the prevalence of overweight and obesity is not limited to
adults. According to the CDC pediatric nutrition surveillance data, which
are collected primarily from the WIC program, the prevalence of overweight
children age 2 and older (but younger than 5), increased by almost 36
percent from 1989 to 1999. 8 In 1999, almost 10 percent of children in this
age group were overweight or obese. Some children are at even greater risk.
Hispanic children, a growing segment of the WIC population, had the second
highest prevalence of being overweight according to the 1999 CDC pediatric
surveillance data. For both adults and children, being overweight and obese
is associated with a variety of health problems, including diabetes, heart
disease, and some types of cancer. As the prevalence of overweight and
obesity has increased, research suggests that the incidences of diabetes
during pregnancy 9 and diabetes in adults have also increased. 10

Recognition of this epidemic, particularly its effect on low- income women
and children, has increased the pressure on WIC agencies to adapt their
nutrition services to help prevent and treat overweight, obesity, and

7 According to the CDC, obesity is defined as an excessively high amount of
body fat in relation to lean body mass. Overweight refers to increased body
weight in relation to height, when compared to some standard of acceptable
or desirable weights. Body Mass Index (BMI), which measures a person?s body
weight divided by the square of his or her height, is more highly correlated
with body fat than any other indicator of height and weight. Individuals
with a BMI of 25 to 29. 9 are considered overweight, while individuals with
a BMI of 30 or more are considered obese.

8 These data have not been analyzed to compare the prevalence of overweight
in children participating in WIC with children not participating in WIC. 9
Ferrara A, Quesemberry CP, Riley C, Hedderson MM, Kahn HS, ?Changes in
prevalence of gestational diabetes mellitus (GDM): Northern California,
1991- 1999? [Abstract] Diabetes,

2001; 50 (Supplement 2). Presented at the 61st Scientific Section of the
American Diabetes Association Meeting, Philadelphia, Jun. 22- 26, 2001.

10 AH Mokdad, ES Ford, BA Bowman, DE Nelson, MM Engelgau, F Vinicor, and JS
Marks,

?Diabetes trends in the U. S.: 1990- 1998? Diabetes Care, 2000 23: 1278-
1283. Obesity Epidemic Poses New

Challenges for Nutrition Education

Page 12 GAO- 02- 142 WIC Challenges

related health problems. In addition to helping to respond to this epidemic,
WIC must continue to serve low- income women and children who are
susceptible to other diseases, some new and some long- standing, such as
anemia, HIV/ AIDS, elevated levels of lead in blood, and tooth decay. The
nutrition education and breastfeeding promotion activities provide an
opportunity for WIC staff to help participants prevent these diseases.
However, WIC faces several obstacles- such as limited time and resources- in
adapting its nutrition education to respond to these new and long- standing
health issues.

WIC staff has limited time to provide the type of counseling needed to
discuss disease prevention. Our study of six local WIC agencies found that
individual nutrition education sessions did not last long, ranging from an
average of 4 minutes to 17 minutes among the six agencies. In addition, WIC
regulations require only two nutrition education contacts during each 6-
month WIC certification period. It is difficult to help prevent numerous
nutrition- related diseases with a few brief nutrition education sessions.

WIC nutrition education was originally intended, according to USDA
officials, to provide a relatively basic message about the value of good
nutrition to low- income pregnant and postpartum women whose diets were
inadequate. To help address more complex nutrition problems, such as
obesity, according to a CDC expert on nutrition, WIC?s nutrition education
needs to be fundamentally changed in several ways. This expert indicated
that nutrition education has focused traditionally on advising families to
eat more fruits and vegetables. He suggests it now needs to focus more on
teaching parents that they need to be responsible for the types of food
offered to their children and let children decide how much to eat. In
addition, the CDC expert indicated that the scope of nutrition education
needed to be expanded to include such topics as physical activity,
television viewing, and fast foods.

Local WIC agencies tend to rely on two techniques to provide nutrition
education. According to a 1998 USDA survey, over three- quarters of local
WIC agencies always used counseling/ discussion and written materials to
provide nutrition education. 11 Less than 10 percent of the agencies in the
survey reported using other techniques such as food tasting or videos to
provide nutrition education. Several experts have suggested that WIC

11 Abt Associates, Inc., WIC Participant and Program Characteristics 1998,
Food and Nutrition Service, USDA: Alexandria, VA, WIC- 00- PC, May 2000.

Page 13 GAO- 02- 142 WIC Challenges

agencies need to use multiple teaching techniques. They also suggested that
these techniques be tailored to each participant and that the participant be
included in designing the education that best meets his or her needs.

While USDA has undertaken several initiatives, existing resources appear to
limit the program?s ability to address emerging health issues. 12 To develop
and implement a response to diseases such as obesity, WIC would need to
devote additional resources to nutrition education, according to CDC and
USDA officials. Devoting resources to address new health issues may come at
the expense of other program priorities. In addition, current WIC program
regulations on the use of resources may limit the effectiveness of the
response to some emerging health issues. For example, costs associated with
providing physical activity classes and equipment, which appear to be
important in addressing weight problems, are not allowable expenditures.

Any strategies that WIC employs to address health issues such as obesity
would have to contend with some formidable social forces. Two of these
forces are the prevalence of advertising and the decrease in physical
activity. Advertising has a significant impact on eating behaviors. For
example, one study found that 1 or 2 exposures to advertisements of 10 to 30
seconds could influence preschool children to choose low- nutrition foods.
13 Research also shows that several environmental trends, such as increased
television viewing and increased consumption of fast foods, have contributed
to obesity nationally. 14

According to government statistics, numerous changes in the demographics of
the nation?s population have occurred during the 1990s. Several of these
changes- shifts in the population?s ethnic composition, increases in the
number of working women, and the growing number of preschool children
enrolled in daycare- were also seen in the WIC- eligible

12 According to USDA officials, these initiatives include the development of
the WIC Works Resource System and funding grants to selected state agencies
to explore strategies to address childhood obesity.

13 Borzekowski, Dina L. G., Robinson, Thomas N., ?The 30- second effect: An
experiment revealing the impact of television commercials on food
preferences of preschoolers,?

Journal of the American Dietetic Association, Volume 101, Number 1; Jan.
2001, pp. 42- 46. 14 French, Simone A., Story, Mary and Jeffery, Robert W,
?Environmental Influences On Eating And Physical Activity,? Annual Review of
Public Health, 2001, Vol. 22: 309- 335. Participant Demographics Have

Changed Over the Past Decade

Page 14 GAO- 02- 142 WIC Challenges

population. WIC is faced with the challenge of responding to each of these
changes.

Ethnic Composition

Over the years, the ethnic composition of the WIC population has changed. In
1988, almost half of WIC participants were white and over one- quarter were
African- American. The composition began to change in the mid1990s when the
number of Hispanic WIC participants began to grow. Between 1994 and 1998,
the percentage of WIC participants who were Hispanic increased from 26
percent to 32 percent. 15 During the same period, the percentage of WIC
participants who were African- American declined from about 25 to 23
percent, while there were only slight changes among other racial or ethnic
groups. Some WIC agencies serve more ethnically diverse communities than
others. For example, three of our five local case study agencies served
predominantly white communities, while two agencies served very diverse
populations. One local agency director reported that less than one- quarter
of their WIC participants spoke English as a primary language.

As a result of the changing make- up of WIC?s participant population, WIC
agencies are faced with the challenge of providing nutrition services that
are culturally and ethnically appropriate, as the program requires. Recent
data suggests that WIC agencies offer nutrition education in several
languages. Over half of the local agencies responding to a 1998 USDA survey
indicated that nutrition education was available in Spanish. 16 Providing
nutrition education and other services in a foreign language requires
agencies to employ staff members who speak languages other than English or
pay for interpreter services which can be costly. 17 In addition, USDA and
state and local WIC agencies have developed teaching materials, such as
brochures, in foreign languages.

15 See WIC Participant and Program Characteristics 1998 cited previously. 16
See WIC Participant and Program Characteristics 1998 cited previously. 17 In
April 2001, the American Medical Association requested that the Department
of Health and Human Services not enforce department policy that requires
physicians treating Medicaid patients to hire clinical interpreters to
assist in the treatment of patients with limited English proficiency because
the cost to retain an interpreter can exceed the Medicaid compensation for
the care.

Page 15 GAO- 02- 142 WIC Challenges

WIC agencies may need to increase staff awareness of the different
nutritional needs and preferences of the various ethnic and cultural groups
that they serve. For example, research conducted in the early 1990s
involving urban African- American WIC mothers suggested a tendency to
introduce infants to solid food in the first few weeks of life, rather than
waiting 4 to 6 months, as recommended. 18 This practice occurred despite
receiving WIC counseling and educational materials. Understanding the
distinctive nutritional preferences of participant groups requires WIC staff
to dedicate time to studying different cultures and related health and
nutrition research, a particularly challenging task for WIC agencies that
serve several ethnic or cultural groups.

Working Women

As composition of the WIC population has changed, the percentage of women in
the WIC program who work has increased, according to some state WIC
officials. In 1998, about 25 percent of women who were certified or
certified a child for the WIC program were employed, according to data
provided by USDA. 19 While no data exist on the change in recent years in
the percentage of women participants who are working, data from Bureau of
Labor Statistics suggest that work activity has increased in low- income
households with children. 20 Between 1990 and 1999, the percent of children
living below the poverty level in families maintained by two parents with at
least one parent employed full- time increased from 44 to 52 percent. The
percent of poor children living in families maintained by a single mother
employed full- time increased from 9 to 18 percent.

To respond to the increase in working WIC families, WIC agencies are faced
with the challenge of making nutrition services accessible to individuals
with greater constraints on their time. Some WIC agencies have offered
services that accommodate individuals who keep traditional

18 Bronner Y. L., Gross S. M., Caulfield L., Bentley M. E., Kessler L.,
Jensen J., Weathers B., Paige D. M., ?Early Introduction of Solid Foods
Among Urban African- American Participants In WIC,? Journal of the American
Dietitians Association, Apr. 99( 4): 457- 61. Bentley M., Gavin L., Black M.
M., Teti L., ?Infant Feeding Practices Of Low- Income, African- American,
Adolescent Mothers: An Ecological, Multigenerational Perspective,? Social
Science & Medicine, 1999, V49, N8 (Oct.): 1085- 1100.

19 Data provided by the Food and Nutrition Service, USDA, (Aug. 2001). 20
Federal Interagency Forum on Child and Family Statistics, America?s
Children: Key National Indicators of Well- Being, 2001, Federal Interagency
Forum on Child and Family Statistics, Washington, DC: U. S. Government
Printing Office, Jul. 2001.

Page 16 GAO- 02- 142 WIC Challenges

work hours. For example, 26 percent of the local WIC agencies responding to
USDA?s 1998 survey indicated that they offered extended hours, such as
evening or weekend hours; fewer than 3 percent had mobile facilities that
could potentially visit work or community sites. 21 Four of our five local
case study agencies offered extended hours on a few days each month, either
in the evenings or on weekends, for a few hours.

Several factors may limit the ability of local agencies to improve access to
services for participants who work. First, local agencies may lack the
resources to pay for the staff or the security needed to have their sites
open during evening or weekend hours. Second, federal regulations generally
require participants to pick up vouchers in person when they are scheduled
for nutrition education or for recertification, which limits WIC agencies?
ability to employ other strategies such as mailing vouchers to participants?
homes. Third, providing WIC services at nontraditional locations, such as
grocery stores, that may be more convenient for those who work, may infringe
on the participants? privacy and present a conflict of interest.

The increase in the number of WIC participants who work will make attaining
some of WIC?s goals, such as increasing breastfeeding, a greater challenge.
Employer policies can affect the length of time a woman employee
breastfeeds. One study found that the duration of the work leave
significantly contributed to the duration of breastfeeding. 22 In addition,
businesses that employ WIC mothers may not provide accommodations that
support daily breastfeeding needs. A 1996 survey of over 500 WIC mothers
found that less than 2 percent of those who went to work or school reported
having such accommodations, such as the ability to bring a baby with them or
being provided facilities for breastfeeding. 23 In 2000, WIC mothers who
worked full- time had the lowest breastfeeding rate for infants at 6 months
of any category of WIC mothers, even though they initiated breastfeeding in
the hospital at about the same rate as other

21 See WIC Participant and Program Characteristics 1998 cited previously. 22
Roe, B., Whittington, L. A. Fein, S. B., Teisl, M. F., ?Is there Competition
between Breastfeeding and Maternal Employment?? Demography, Vol. 36, No. 2,
May 1999, pp. 157- 171. 23 Bronner, Y., Gross, S. Caulfield L., Bently, M.,
Jensen, J. Kessler, L., Paige. D. ?Influence

Of Work Or School On Breastfeeding Among Urban African American WIC
Participants,?

Abstracts of the 124th Annual Meeting, American Public Health Association,
Nov. 17- 21, 1996, New York City, Session #3090, p. 430.

Page 17 GAO- 02- 142 WIC Challenges

mothers. 24 To respond to this challenge, WIC staff might need to work with
employers and schools to encourage the adoption of procedures and facilities
that support breastfeeding among employees and students.

Children in Daycare

As a result of the increase in the number of working parents, low- income
children are increasingly placed in daycare. In a recent study, we concluded
that since the implementation of TANF, more low- income children were in
care outside the home and were in this care earlier in their lives. 25
Children who are in daycare may be unable to accompany their parents to WIC
office visits for vouchers and nutrition education. As a result, WIC staff
may have little opportunity to provide age- appropriate nutrition education
directed at preschoolers, though evidence suggests such education
contributes to positive eating behaviors. According to USDA?s 1998 survey,
only about 38 percent of local WIC agencies provided nutrition education
directed to WIC preschoolers. Since meals and snacks are usually provided in
daycare settings, daycare providers play an important role in shaping the
nutritional behavior of preschoolers. As more low- income preschoolers enter
daycare, WIC may need to explore ways to broaden its nutrition education
efforts to include the daycare providers serving WIC children more
systematically.

WIC faces the challenge of maintaining a skilled staff. The quality of
nutrition services depends, to a large degree, on the skills of the staff
delivering the services at the local WIC agencies. Yet, due in part to the
widespread difficulty in hiring professionals, local agencies are
increasingly relying on paraprofessionals to provide services. At the same
time, social and systemic changes have heightened the need for WIC staff to
learn new skills. However, investing in training is difficult for agencies
with limited resources. Possible solutions to address WIC?s staffing and
training needs are unclear because the staffing needs have not been assessed
and there is not a defined commitment to training.

24 Abbott Laboratories, ?Breastfeeding Trends in the U. S. and WIC
Population Demographics,? Presentation to the Panel to Evaluate USDA?s
Methods for Estimating Eligibility and Participation in the WIC Program,
Committee on National Statistics, Commission on Behavioral and Social
Sciences and Education, the National Academies, Washington, DC, Mar. 15,
2001.

25 Education and Care: Early Childhood Programs and Services for Low- Income
Families (GAO/ HEHS- 00- 11, Nov. 15, 1999). The Challenge of

Maintaining a Skilled Staff

Page 18 GAO- 02- 142 WIC Challenges

Many local WIC agencies recently reported an insufficient number of
professional staff and difficulty acquiring professional staff members. A
1998 USDA survey found that 30 percent of local WIC agencies serving over 40
percent of WIC participants reported having too few professional staff
members. About half of all WIC agencies reported having difficulty
recruiting and hiring professional staff. We estimated, based on information
obtained from our survey of local WIC agencies, that in fiscal year 1998
between 5 percent and 15 percent of local WIC agencies did not have a
nutritionist or dietitian on staff.

The shortage of professional staff at WIC agencies is influenced by several
factors, some of which are external to the WIC program. The most commonly
reported difficulty associated with recruiting and hiring professional staff
was that the salaries and/ or benefits were not competitive. Another
commonly reported difficulty was the lack of qualified applicants. According
to a director of the American Dietetic Association, several factors may
negatively affect the ability of WIC agencies to recruit registered
dietitians, including the mundane nature of the work and the rural location
of many agencies.

The shortage in professional staff may worsen in the coming years. According
to the Association director, who is also a state WIC director, WIC?s
workforce is aging and a large number of professionals are expected to
retire in the next few years.

Many local agencies are relying more on paraprofessionals to provide
nutrition services. According to data from USDA surveys, paraprofessionals
now perform tasks that were once performed by professionals. In 1988, fewer
than 2 percent of local agencies reported using paraprofessionals to provide
nutrition education to high- risk participants and between 11 and 18 percent
reported using them to provide nutrition education to low- risk
participants. By 1998, this had changed considerably. That year, about 17
percent of agencies used paraprofessionals, along with professionals, to
provide nutrition education to high- risk individuals and between 42 percent
and 50 percent used them to provide nutrition education to low- risk
individuals.

The shift towards a greater reliance on paraprofessionals may be attributed
to several factors. The difficulty in hiring professionals and the WIC
Agencies Report a

Shortage of Professionals That May Worsen

WIC Agencies Increasingly Rely on Paraprofessionals to Deliver Services

Page 19 GAO- 02- 142 WIC Challenges

foreign language skills more often possessed by paraprofessionals 26 may
both play a role in this phenomenon. In addition, USDA officials pointed out
that the required qualifications for competent professional authorities, who
provide nutrition services, are ?ridiculously low.? 27 Consequently, WIC
agencies are able to hire paraprofessionals to positions previously filled
by professionals.

As a result of the increased reliance on paraprofessionals, USDA officials
and other experts have become concerned that the quality of nutrition
services will suffer. The types of services that agencies offer may become
increasingly limited without staff whose qualifications support a full range
of services. Already, some WIC agencies have limited the services they
provide. For example, in Montana where some local WIC agencies did not have
registered dietitians on staff, state policy in 1999 prohibited all local
WIC agencies from providing the type of nutrition counseling needed to
address conditions such as gestational diabetes. According to a local agency
director, not only did this restriction affect the quality of services
provided to participants, but also it was a disincentive for registered
dietitians to apply for WIC jobs because it limited their ability to use
their skills.

Given the changes in the WIC population and the environment in which the
program operates, WIC agencies face an increased challenge of ensuring that
their staff have the skills and knowledge to provide effective nutrition
services. Many WIC staff may not have the skills and knowledge necessary to
meet new client needs. For example, CDC, USDA, and other experts suggest
that WIC staff currently lack the skills to address some emerging complex
health issues, such as obesity. In addition, WIC staff may not have the
knowledge to navigate the new environment introduced by changes in the
health and welfare system. For example, the Emory University Rollins School
of Public Health publication has suggested WIC

26 Several case study agencies relied on the paraprofessional staff to
provide assistance in translation. 27 Federal regulations require that every
local agency have a competent professional authority and a designated
breastfeeding promotion coordinator. The program does not require that
competent professional authorities have a minimum level of professional
training in nutrition, education, or counseling. Competent professional
authorities can be either professionals- such as dietitians, nutritionists,
nurses- or paraprofessionals, such as individuals who have completed
competency- based training. The program also does not require that a
competent professional authority provide the nutrition education or
breastfeeding support. Staff Lack Needed Skills, but

Allocating Limited Resources to Training Is Difficult

Page 20 GAO- 02- 142 WIC Challenges

staffs? lack of understanding of the managed health care system has posed a
barrier to effective coordination with managed care providers.

To help address this lack of skills and knowledge on the part of WIC staff,
more training may be needed. According to a CDC nutrition expert, to address
emerging health problems, staff must learn to assess participants?
willingness to improve their eating practices and to tailor education to
improve participants? behaviors. In addition, WIC staff needs extra
information to provide services in a changing social service environment.
For example, they need to understand new requirements with which their
participants must comply in order to obtain health care services from
managed care providers.

While WIC regulations require that state agencies provide in- service
training and technical assistance to professional and paraprofessional staff
involved in providing nutrition education, USDA officials indicated that no
defined commitment has been made to improve the training opportunities for
WIC staff. Without such a commitment, some local WIC agencies may be less
inclined to invest limited staff time or funding in training or continuing
education. For example, one case study agency reported that, because funding
constraints left the agency short- staffed, professional staff were
performing more clerical duties and had little time for professional
development. Another local WIC agency director indicated that her program
could not afford to have her attend an annual NAWD conference, even though
the conference was being held locally.

USDA has no current data about the size and composition of the WIC
workforce, a situation that makes addressing staffing and training problems
difficult because little is known about the exact nature of the staffing
problems. Until 1991, USDA did collect some detailed WIC staffing data for
its annual report of WIC administrative expenditures. However, according to
USDA officials, one of the reasons the agency stopped collecting these data
was to reduce the reporting burden on WIC agencies. While surveys of local
agencies conducted for the biannual participant and program characteristics
study in 1996 and 1998 gathered some limited data regarding the sufficiency
of staff levels, there has been no recent study on the size and composition
of the WIC workforce.

The lack of data regarding the WIC workforce can present a barrier to
developing and implementing strategies to address the workforce challenges
facing the program. For example, in 1996 the National Advisory Council on
Maternal, Infant, and Fetal Nutrition recommended that USDA explore with HHS
revising the National Health Service Corps programs to Lack of Data About
the WIC

Workforce Can Hinder Ability to Maintain Skilled Staff

Page 21 GAO- 02- 142 WIC Challenges

include nutrition services as a designated ?primary health service.? This
change would allow federal funds to be used to recruit and train registered
dietitians and nutritionists to work in under- served areas. To do this,
however, USDA needed data showing sufficient demand for registered
dietitians and nutritionists in under- served communities. Although the
Council repeated its recommendation in 2000, to date USDA has not collected
data regarding the need for public health nutritionists in underserved
areas. USDA is sponsoring a survey of the public health nutrition workforce.
The survey results, expected to be published in 2002, will include a
description of the qualifications, training needs, and other characteristics
of the 1999- 2000 WIC workforce. However, the survey will not provide
information on the demand for dietitians and nutritionists in under- served
areas.

State and local WIC agencies are faced with the challenge of delivering
participant services and managing program operations with outdated or
unavailable information technology resources. More than half of state WIC
agencies have management information systems that are not capable of
automatically performing all the program tasks considered essential by USDA.
In addition, while 16 states have been involved in the testing of electronic
transfer of WIC benefits, only one statewide system has been implemented.
Finally, almost one- fourth of the state WIC agencies, along with hundreds
of local WIC agencies, do not have Internet access, limiting their ability
to use online resources and communicate with other providers of nutrition
and health services.

According to a March 2001 USDA report, 56 percent of state WIC agency
automated management information systems were not capable of performing, or
efficiently performing, 1 or more of 19 essential program tasks. (A listing
of the 19 essential program tasks is provided in appendix II.) 28 These
tasks were singled out as basic functions that were essential for state
agencies to automate in order to attain efficient program operations. For
example, management information systems should be able to automatically
assess whether an applicant?s income exceeds the maximum income level for
eligibility based on data entered into the system. The system should also be
able to produce food checks corresponding to the participant?s most recent
food prescription at the

28 See Planning for WIC?s Future Technology Needs, Food and Nutrition
Service, USDA: Alexandria, VA, Mar. 2001. The Challenge of

Operating With Inadequate Information Technology

Automated Management Information Systems Not Meeting Operational Needs

Page 22 GAO- 02- 142 WIC Challenges

time the participant is present to pick up the checks at the local clinic
and to detect suspicious grocery store food coupon redemption activity.

The inability of WIC state agencies? automated management systems to perform
essential tasks can encumber agencies? ability to efficiently administer
program operations. For example, at a local WIC agency in Pennsylvania, we
found that the staff was using hand- written index cards to keep track of
participant information because they lacked a sufficient number of computers
to perform that function. Also, the director at this agency had to spend 6
hours each month manually counting the number of participants in the program
to generate the monthly participation report required by the state. This was
necessary because the agency?s management information system was not capable
of automatically preparing the report. 29 A California WIC official told us
that it was difficult for local WIC agencies? automated systems to create
special reports. Because the reports could take up to several months to
complete, some agencies opted not to generate them. 30 A USDA official told
us that the poor quality of automated systems in some states negatively
affects federal and state efforts to monitor WIC agencies. Because of
computer inadequacies, some states have not been able to provide USDA with
requested data on breastfeeding initiation rates, hampering officials?
ability to assess the effectiveness of breastfeeding promotion.

Most states face one or more of the following obstacles that make it
difficult to bring their automated systems up to the basic level of
functionality:

 Limited funds. States must meet their management information needs almost
entirely from their federal NSA grants. Other funds typically available from
outside sources to help defray WIC costs, including those associated with
information systems, have declined over the last decade. 31 According to
USDA, the cost of bringing WIC?s essential program tasks up to standard in
all states over the next 6 years is between $147 million and $267 million.

29 The Pennsylvania WIC director reported that the state is in the process
of upgrading its management information system; to date, the design phase
has been completed. Hardware and software upgrades will occur over the next
several years as resources permit.

30 Computer upgrades giving California local WIC agencies the ability to
prepare special reports were being planned at the time of our review. 31 See
Food Assistance: Activities and Use of Nonprogram Resources at Six WIC
Agencies, (GAO/ RCED- 00- 202, Sep. 29, 2000).

Page 23 GAO- 02- 142 WIC Challenges

 Outdated technology. According to USDA and other federal studies, the life
cycle for a WIC automated system is 7 years. After that time, the states?
systems do not lend themselves easily, if at all, to technological advances.
About 34 percent of WIC state- level agencies have automated systems that
have exceeded their life cycle, 28 percent have systems that will exceed
their life cycles in 1 to 3 years, and 38 percent have systems with 4 or
more years remaining in their life cycles. 32

 Coordination with other systems. WIC was designed to operate in
conjunction with programs offered by other social and health- related
service agencies. Changes that have occurred in these programs have
complicated the ability of WIC program managers to define the functions that
their automated systems must support and to identify the system
requirements, including the necessary applications and hardware needed to
effectively coordinate WIC with other programs.

 Lack of information technology staff. State and local WIC agencies have
difficulty competing with the salaries and benefits offered by private
sector employers. This can affect their ability to recruit and retain
qualified information technology staff needed to develop and maintain their
automated systems.

Currently, most WIC food transactions involve paper checks. However,
concerns have been raised about the cost to grocers of processing checks and
the inconvenience they present to WIC participants. Electronic benefits
transfer (EBT), an automated process that allows food to be paid for
electronically, offers an alternative to paper checks. With EBT,
participants are given a plastic card, similar to a credit or debit card,
containing their food benefit prescription to purchase benefits at the
grocer?s checkout. USDA and state WIC agencies are exploring the use of EBT
in the WIC program to improve the benefit delivery process.

Paper checks have a number of drawbacks. A 2000 Food Marketing Institute
study that compared the use of WIC?s paper checks for the purchase of food
to other methods- including cash, checks, credit and debit cards, food
stamps, and EBT- found that WIC checks are among the most costly payment
methods for food retailers. 33 The study indicated that the primary reasons
for this higher cost are that store staff take more time to process paper
checks when goods are purchased and to prepare checks

32 See Planning for WIC?s Future Technology Needs cited previously. 33 Food
Marketing Institute It All Adds Up: An Activity Based Cost Study of Retail
Payments, Food Marketing Institute: Washington, D. C., 2000. Electronic
Benefits Transfer

Can Streamline the Delivery of WIC Benefits

Page 24 GAO- 02- 142 WIC Challenges

for bank deposit. In addition to high costs, paper checks can cause
confusion and delays for both the participant- shopper and the store clerk
at the checkout counter and result in unwanted attention. 34

Thus far, EBT for WIC has proven to be much more expensive than paper for
states testing this evolving technology, according to USDA officials.
However, compared to the use of WIC paper checks, EBT is less expensive for
food retailers because it reduces handling costs. In addition, EBT can
provide participants with greater flexibility in purchasing food. For
example, it will allow them to purchase their benefits in quantities as
needed within their issuance period. With paper checks, a participant must
purchase all items on the food instrument when shopping or forfeit the
benefit. EBT can also provide state officials with documentation of WIC
purchases for submitting rebate claims to food manufacturers. By tying EBT
to a product code of authorized WIC foods, the program has assurance that
participants purchase the prescribed foods and do not improperly substitute
foods. EBT may also curtail the waste, fraud, and abuse that can occur with
paper checks.

USDA is exploring the use of EBT to eliminate the need for paper checks.
Since 1991, the agency has provided a total of about $22 million for
demonstration projects involving 16 states to explore the use of EBT
technology for the delivery of WIC benefits. However, no one knows how soon
the widespread use of EBT will be realized in each state, or exactly what
form the new issuance system will take. As of October 2001, only Wyoming had
implemented a statewide WIC EBT system. Federal legislation, developments in
the food retail and electronic funds transfer industries, and emerging
technologies will shape the timing and nature of EBT implementation.

According to USDA officials, WIC had two overall concerns in venturing into
EBT: the technical feasibility and affordability of implementing EBT
systems. In the few state projects where EBT has been tested, the first
concern has been addressed- EBT is technically feasible. However, so far its
affordability for use in WIC remains elusive. According to USDA officials,
EBT costs are far beyond what most states can afford within their available
NSA funds. WIC agencies would need to modify their NSA funding priorities or
find new sources of funds to support their EBT

34 See Food Assistance: Working Women?s Access to WIC Benefits, (GAO/ RCED-
98- 19, Oct. 16, 1997).

Page 25 GAO- 02- 142 WIC Challenges

projects. USDA officials also told us that these costs have had to be funded
by federal grants at the sacrifice of other competing program priorities.

Furthermore, because EBT processes differ in so many respects from those
involving paper checks, agencies may face some of the following obstacles in
implementing EBT:

 Limited federal funds. The potential cost of starting up and operating EBT
is an issue of considerable importance to all state and local WIC agencies.
These costs may not be covered by their NSA funds allocated for technology
expenditures. As a result, WIC agencies would need to modify their NSA
funding priorities or find new sources of funds to support their EBT
projects.

 Outdated technology. Some local WIC agencies are unable to use EBT because
they do not have computers, or they have computers that are unable to
accommodate the necessary technology. WIC computer equipment must have the
processing speed and communications capability to electronically transmit
EBT data. In addition, software changes may also be needed to enable older
systems to operate in conjunction with EBT.

 Lack of an industrywide standard. An industrywide standard for EBT systems
that could be used for WIC transactions has not yet emerged. The various EBT
technologies must be compatible with retailers? normal transaction systems
to perform the purchase function. The integration of different EBT
technologies requires a common operating system standard, such as those used
by credit card companies. The absence of such a common nationwide standard
makes the widespread development of EBT applications very difficult.

The Internet can be used by federal, state, and local agencies for a variety
of purposes related to the WIC program. USDA uses the Internet to provide
state and local WIC agencies with program information, such as eligibility
guidelines, application instructions, program funding, participation rates,
and current laws and regulations. USDA also uses the Internet to provide
research and training to health and nutrition professionals, including those
outside of WIC. USDA has plans to use the Internet to disseminate
information to help reduce program fraud and to collect information directly
from grocery stores participating in the WIC program. About half of the
state agencies and some local agencies that have Internet access have
established Web sites for their WIC programs. These sites have been used to
provide information- including eligibility guidelines, application
procedures, program benefits, and clinic Internet Access Could Enhance

Information Exchange

Page 26 GAO- 02- 142 WIC Challenges

locations- to WIC participants and potential applicants. In addition, some
local WIC agencies use the Internet to e- mail state agencies and obtain or
provide information on nutrition activities and services.

According to USDA, 68 of the state- level WIC agencies had the capability to
access the Internet as of July 2001. The capability of local WIC agencies to
access the Internet is more difficult to ascertain. However, according to
the Director of the National Association of WIC Directors, about half of
their 600 local agency members currently have the ability to access the
Internet. 35

While the Internet is being used extensively by USDA and many state and some
local agencies, the following obstacles have discouraged or prevented some
state and local WIC agencies from obtaining Internet access:

 Limited funds. Accessing the Internet requires the necessary computer
equipment that many local WIC agencies and/ or their clinics do not possess.
The costs of computer installation must compete against other WIC funding
demands, such as salaries, utilities, and supplies. Even with the necessary
computer equipment, local WIC agencies and/ or their clinics may choose to
forgo Internet use in some areas because they may have to pay costly long
distance charges for the telephone connections to the Internet provider from
funds that are competing with other more essential program needs.

 Security concerns. Although local agencies may have the computer
capability to access the Internet, concerns regarding the security
vulnerabilities inherent with the use of the Internet, including
unauthorized access to files and hostile ?virus? attacks on computer
systems, may discourage its use. For example, the Pennsylvania WIC agency
prohibits Internet connections by its local agencies primarily because of
concerns regarding the potential harm that could result from the improper
access to sensitive personal information gained by unauthorized persons.

35 The National Association of WIC Directors represents the state,
territorial, and Native American WIC directors and the nearly 1, 900 local
agencies that provide WIC services through more than 10, 000 WIC clinics
nationwide.

Page 27 GAO- 02- 142 WIC Challenges

In attempting to be responsive to recent requests from the Congress and
others, WIC faces the challenge of assessing the effects of providing
specific nutrition services. According to USDA officials, the focus on
assessing the effects of specific nutrition services is a shift from the
early years of WIC when assessments focused on the outcomes associated with
overall program goals, such as reducing national rates of anemia, infant
mortality, and low birth weight. In order to assess the effects of specific
nutrition services, such as nutrition education, USDA needs good outcome
measures for each service, consistent information from states regarding the
attainment of goals and objectives for each service, and reliable research
on the effectiveness of each service. However, to date, the agency has been
able to collect data on only one outcome measure related to breastfeeding
promotion and support. In addition, USDA has obtained inconsistent data on
state goals and objectives and limited information from research studies on
the effectiveness of specific nutrition services.

To meet the Government Performance and Results Act requirements, USDA has
attempted to develop national outcome measures that would allow the agency
to determine the effectiveness of WIC?s nutritional services. 36 To date,
USDA has had limited success in establishing national outcome measures for
WIC?s three key nutrition services- nutrition education, breastfeeding
promotion and support, and health referrals.

USDA has been able to collect information on only one outcome measure:
breastfeeding initiation rate. This measure helps determine the
effectiveness of a single nutrition service, breastfeeding promotion and
support. Not only is this outcome measure relevant to only one nutrition
service, but it also looks at a limited aspect of this service. The
breastfeeding initiation rate examines only one of several important aspects
of the service?s possible impact on breastfeeding. It does not measure the
length of time that WIC mothers breastfeed infants because, despite USDA?
effort to collect data on the duration of breastfeeding, most state agencies
were unable to give the agency complete information on this measure. In
addition, USDA was unable to collect data on an outcome measure that would
determine the percentage of WIC infants? daily nutrition obtained through
breastfeeding because the agency was unable to identify a viable way to
collect these data.

36 See Food Assistance: Performance Measures for Assessing Three WIC
Services

(GAO/ 01- 339, Feb. 28, 2001). The Challenge of Assessing

the Effect of Nutrition Services

Only One Outcome Measure Has Been Implemented Thus Far

Page 28 GAO- 02- 142 WIC Challenges

Although USDA has identified outcome measures for other nutrition services,
obstacles have hindered the agency?s success in collecting relevant data.
These obstacles include difficulties in identifying the type of data to
collect because many variables may be influencing outcomes. For example,
there are several other state and local programs that, like WIC, are aimed
at improving health through nutrition education. Separating the effects of
these efforts from those of the WIC program is difficult at best. USDA has
also had few resources to collect appropriate data on measures it
identifies. As a result, USDA is unable to implement most outcome measures.
USDA?s difficulties in measuring WIC outcomes are not unique. In a previous
study, we found that programs that do not deliver a readily measurable
product or service or are intergovernmental grant programs have difficulty
producing performance measures. 37

As NSA grant recipients, state agencies are required to describe their goals
and objectives for improving program operations in their annual program plan
given to USDA. However, we found that for several reasons, this information
does not provide USDA the data necessary to describe the extent to which WIC
is meeting its intended NSA goals.

First, no requirement exists that state goals and objectives be reported in
a consistent format to USDA. Without consistent information, it is difficult
for USDA to aggregate reported state performance information on a regional
or national basis. Second, there is no requirement that the goals or
objectives be measurable. Our review of a sample of over 400 state goals and
objectives for nutrition services from 25 state WIC agencies revealed that
over half lacked key information, such as baseline or target values, needed
to measure progress toward improving program operations. 38 Third, we
observed that the specificity in the description of the goals or objectives
varied significantly. For example, some objectives were short, general
statements such as, ?continue to improve the data integrity of the WIC data
warehouse.? Other objectives were very detailed,

37 See Grant Programs: Design Features Shape Flexibility, Accountability and
Performance Information (GAO/ GGD- 98- 137, Jun. 22, 1998). 38 Goals and
objectives from fiscal year 2001 plans were provided to us by 74 state-
level agencies. We randomly selected 25 of these agencies for this analysis.
Each goal and objective was independently reviewed by two GAO analysts to
determine whether or not the goal or objective could be measured and whether
or not the goals and objectives focused on nutrition services. Discrepancies
between the analysts were resolved, so that there was 100 percent agreement.
The data presented here are based on the analysis of those goals and
objectives that focused on nutrition services. USDA Has Limited Information

Regarding State Goals and Objectives

Page 29 GAO- 02- 142 WIC Challenges

including such information as the activities undertaken to achieve the
objective. Moreover, a wide range existed in the number of goals or
objectives identified. For instance, one state had 2 goals and 2 objectives,
while another state had 13 goals and no objectives, and still a third had no
goals and 24 objectives.

Last, unlike the Department of Health and Human Services? (HHS) Maternal and
Child Health Services Block Grant Program, state WIC goals and objectives
are not readily available for review, nor is progress toward the goals
automatically tracked. As of late 2000, USDA had not compiled the state
goals and objectives. Nor did it have the capability to do so easily. The
ability to automatically track outcomes appears to be limited, in part, by
data collection at the state- level agencies. For example, according to USDA
officials, fewer than half of the state- level agencies were able to provide
sufficient data on the duration of breastfeeding because the automated
information systems did not contain complete data on each participant.

Few research studies exist on the effects of specific nutrition services. In
a prior report, we identified seven such studies published between 1995 and
2000. 39 Four of the studies examined the impact of breastfeeding promotion
and support, two focused on health care referrals, and one examined both
nutrition education and breastfeeding promotion and support. However, the
results of these studies provide few, if any, insights into the effects of
specific WIC nutrition services. One reason so few successful impact studies
exist is the difficulty many researchers face in conducting them.
Researchers encounter difficulties because of the following:

 Data constraints. We found that the nature of available data severely
limited the usefulness of several of the impact studies of WIC nutritional
services. The three major sources of WIC data are USDA?s WIC Participant and
Program Characteristics (PC) data, and CDC?s Pediatric Nutrition
Surveillance System (PedNSS) and CDC?s Pregnancy Nutrition Surveillance
System (PNSS). The PC data, which has been collected every 2 years since
1988, provides a snapshot of the characteristics of WIC enrollees at the
time data are collected. The PedNSS and PNSS annually track the health
status of children and the risk factors of mothers who

39 See GAO- 01- 442 cited previously. Research That Determines the

Effectiveness of WIC Services Is Limited

Page 30 GAO- 02- 142 WIC Challenges

participate in selected federal programs, including WIC. 40 Since none of
these data sources currently track the same individuals over time or collect
information on the types of services that individual participants receive,
researchers cannot use the data to associate WIC services with changes in
participant characteristics. In addition, the available data from other
national surveys may be too old to reflect current demographics or services.

 Research design. Research design can be problematic. To determine the
effect of services, research must assess the extent to which program
interventions impact its participants. To do this, other possible influences
must be excluded, a task that is best accomplished through the use of random
assignment whereby individuals are randomly placed in either a group
receiving program services or a group denied program services. 41 Research
studies that employ random assignment can be problematic because some
children will be denied program services. This is especially challenging for
a program like WIC that has enough funds to serve all qualified applicants.

 Program variation. WIC agencies can provide their services differently, a
fact that complicates drawing broad conclusions about services? effects.
Because WIC is a grant program, state agencies are given the discretion to
implement key program elements, such as the content of nutrition education,
in a way that suits local needs. This discretion can lead to substantial
variation in the services that WIC participants receive.

 Lack of funding. The lack of sufficient funding, according to USDA and CDC
officials, is another factor that makes it difficult to conduct WICrelated
research. Before 1998, USDA spent about $3. 5 million annually on WIC-
related research- an amount that was insufficient to collect the primary
data and conduct the complex research necessary to assess the effect of WIC
services, according to USDA and CDC officials. 42 This problem is not unique
to USDA. In 1996, we surveyed 13 federal departments and 10 independent
federal agencies and found that relatively

40 In 1999, PedNSS tracked over 5.5 million WIC children with data submitted
from 47 statelevel agencies, while the PNSS tracked over 700,000 pregnant
WIC women with data submitted by 26 state- level agencies.

41 Less rigorous quasiexperimental designs use methods other than random
assignment to create comparison groups. For example, a set of individuals
who have similar characteristics to the group receiving the program services
under study might be selected and compared to the study group.

42 USDA?s Economic Research Service has conducted WIC- related research
since 1998. Funding for Economic Research Service projects in the WIC
program area has declined from about $2. 8 million in fiscal year 1998 to
about $1. 7 million in fiscal year 2000.

Page 31 GAO- 02- 142 WIC Challenges

small amounts of resources were allocated for conducting program evaluations
in fiscal year 1995 and these resources were unevenly distributed across the
agencies. 43

WIC has been faced with the challenge of meeting additional program
requirements with available resources. Since the late 1980s, a number of
requirements have been placed on the program aimed at, among other things,
containing the cost of food benefits, promoting breastfeeding, encouraging
immunizations, and controlling program abuse. While these requirements have
placed additional service delivery and administrative demands on WIC staff,
they have not been accompanied by more funding per participant; the NSA
grant per participant was established in 1989 and since then has only been
adjusted for inflation. There is also evidence that nonfederal support for
NSA may have decreased since fiscal year 1992. Nor have the additional
demands been offset by reductions in other responsibilities. As a result,
WIC agencies have had to cut costs and make changes in service delivery that
potentially will have a negative impact on the quality of WIC services.

Since the late 1980s, new requirements placed on the WIC program have
directly affected service delivery and program administration. Table 1 shows
some of the major federal requirements added since 1988 and the associated
service and administrative responsibilities.

43 See Program Evaluation: Agencies Challenged by New Demand for Information
on Program Results, (GAO/ GGD- 98- 53, Apr. 24, 1998). The Challenge of
Meeting

Increased Program Requirements

Increase in Program Requirements Has Affected Program Operations

Page 32 GAO- 02- 142 WIC Challenges

Table 1: Major New Program Requirements Since 1988 Requirement Source
Responsibilities

Contain food costs The Child Nutrition and WIC Reauthorization Act of 1989
(P. L. 101- 147); and the William F. Goodling Child Nutrition
Reauthorization Act of 1998 (P. L. 105- 336)

States must undertake cost containment measures, including contracts for the
purchase of infant formula and, if possible, other WIC foods. Infant formula
contracts are awarded on the basis of competitive bids from manufacturers.

Educate about drug and alcohol abuse and make related referrals

The Anti- Drug Abuse Act of 1988 (P. L. 100- 690); and the Child Nutrition
and WIC Reauthorization Act of 1989 (P. L. 101- 147)

WIC agencies must provide substance abuse education to WIC participants,
including the referral of participants for treatment. Local agencies are
also required to maintain lists of local providers of substance abuse
counseling and treatment. Increase breast feeding promotion The Child
Nutrition and WIC

Reauthorization Act 1989 (P. L. 101- 147) State WIC agencies must spend a
specified minimum amount of NSA funds on breastfeeding promotion and
support. States must

also (1) designate an agency staff member to coordinate breastfeeding
promotion efforts identified in the state plan of operation and
administration and (2) provide training on the promotion and management of
breastfeeding to staff members of local agencies who are responsible for
counseling participants. Outreach to homeless The Hunger Prevention Act of
1988 (P. L.

100- 435) Local agencies must provide outreach to eligible homeless mothers,
infants, and children.

Register voters The National Voter Registration Act of 1993 (P. L. 103- 31)
WIC agencies must serve as designated voter registration

agencies and perform voter registration activities. Enhance outreach to
eligible participants The Child Nutrition and WIC

Reauthorization Act 1989 (P. L. 101- 147) Local agencies must make follow-
up calls to pregnant applicants who miss appointments.

Improve program accessibility for working and rural women

The Child Nutrition Reauthorization Act 1989 (P. L. 101- 147) and Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (P. L. 104-
193)

Local agencies must schedule appointments to minimize the time employed
participants or applicants are absent from the workplace. States must
develop a plan to improve access to the program for participants and
applicants who are employed or who reside in rural areas. Document income
The William F. Goodling Child Nutrition

Reauthorization Act of 1998 (P. L. 105- 336)

Agencies must obtain documentation of applicants? family income or receipt
of assistance from related programs such as Medicaid or Food Stamps.
Strengthen vendor monitoring The William F. Goodling Child Nutrition

Reauthorization Act of 1998 (P. L. 105- 336)

States must identify vendors who have a high probability of program abuse
and conduct compliance investigations of vendors. Establish minimum
requirements for immunization screening and referrals

Executive Memorandum (Dec. 11, 2000); and WIC Final Policy Memorandum No.
2001- 7 (Aug. 30, 2001)

WIC agencies must place more emphasis on immunization screening and referral
by (1) advising all applicants that immunization records are requested as
part of the WIC certification process (though not required to obtain WIC
benefits); (2) screening immunization status using documented records at
subsequent certifications; (3) assessing the immunization status of children
under 2 by counting the number of doses of specific vaccines that the child
has received; and (4) providing information on recommended immunization
schedules and refer those in need to immunization services.

Little is known about how much meeting these additional requirements will
cost the program. Costs have been estimated for only two of these
requirements. USDA estimated that strengthening vendor monitoring would cost
states and local agencies about $7 million annually. The

Page 33 GAO- 02- 142 WIC Challenges

National Association of WIC Directors estimated that increasing the emphasis
on immunization education, documentation, and referrals could cost as much
as about $37 million annually. Officials from the CDC agreed with NAWD?s
cost estimate.

In recognition of the increased demands that have been placed on the
program, the Congress in recent years has reduced some requirements.
However, according to USDA officials, these reductions do not offset the
additional requirements. The reductions have generally been administrative
in nature and have had little or no impact on the services provided directly
to WIC participants. For example, the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (P. L. 104193) reduced some of the
burden associated with the submission of annual program plans. States are no
longer required to submit a full program plan each year; rather, after a
submitted plan is approved, a state submits only substantive changes in
subsequent years.

Federal mandates are not the only source of increased demands placed on the
program. State WIC agency officials have considerable flexibility to impose
additional program requirements in their states. To contain the cost of
food, state officials have imposed a variety of limitations on the food WIC
participants in their states can select. For example, some states require
participants to purchase the lowest cost brand of an approved food item.
Such requirements place administrative demands on NSA resources because
local agency officials must monitor retailer and participant compliance with
selection limitations. In addition, such requirements can increase the
amount of time needed to explain food selection limitations to participants,
reducing the time spent on needed nutrition education or counseling.

Each year, USDA must use a national per participant NSA grant amount, set by
law, to determine the funding to be used for food and NSA grants. 44 This
per participant grant amount is based on the national average of NSA grant
expenditures that was made per participant per month in 1987, only

44 In 1987, the national average of grants made to states per participant
per month was $8.24. Grant Level Per Participant Has

Not Been Adjusted, Except for Inflation

Page 34 GAO- 02- 142 WIC Challenges

adjusted for inflation. 45 In fiscal year 2001, grant levels were based on a
national average of $12. 27 per participant per month.

Before the average NSA grant per participant was used, funding for NSA was
set at 20 percent of the total WIC appropriation. 46 Since then, the
percentage of federal WIC funds dedicated to NSA has increased to about 27
percent- perhaps giving the impression that, with such a substantial portion
of program funds, NSA funds are sufficient to cover the costs of additional
responsibilities. However, this increase is not the result of more funds per
participant being dedicated to NSA; rather, it is the result of a decrease
in the amount of federal funds needed to cover the food purchasing portion
of the program. Food costs have been dramatically reduced by the infant
formula rebates, in which companies reimburse the WIC program a percentage
of the cost of every can of formula purchased by program participants. UDSA
projects that in fiscal year 2001, savings from infant formula rebates will
total about $1. 5 billion. 47 This amount covers the cost of about 28
percent of food benefits provided to participants. 48 If rebate savings are
considered, NSA has remained roughly 20 percent of total program costs from
1988 through 1999. Figure 2 shows the percentage of program funds spent on
NSA, including and excluding rebate savings.

45 USDA was required by law (P. L. 101- 147) to use fiscal year 1987 as an
adjustment for inflation. Starting in fiscal year 2001, in accordance with a
change in the law (P. L. 106- 224), USDA must now use the preceding fiscal
year as the base year to adjust for inflation.

46 USDA first used the average grant per participant in fiscal year 1990. 47
Under P. L. 101- 147 (Nov. 10, 1989), state agencies are required to procure
infant formula using a competitive bidding system or an alternative method
of cost containment that yields savings equal to or greater than those
produced by a competitive bidding system. Some states had voluntarily
negotiated sole source contracts with infant formula manufacturers before
the sole source rebate requirement went into effect. Some groups of states
jointly have contracted for a sole- source provider of infant formula.
Therefore, the geographic area covered by some contracts may be larger than
a single state.

48 Current program regulations allow states to convert food funds to NSA
funds to cover only current year expenditures under two conditions: (1) a
state has an approved plan for food cost containment and increases in
participation levels above the USDA- projected level and (2) a state?s
participation actually increases above the level projected by USDA.

Page 35 GAO- 02- 142 WIC Challenges

Figure 2: Percentage of WIC Expenditures for NSA - Including and Excluding
Rebate Funds, Fiscal Years 1988- 1999

Source: GAO?s analysis of USDA?s data.

State and local WIC agencies appear to be relying more heavily than they did
in the past on federal grant funds to cover the costs for NSA. Based on our
survey of state and local WIC agencies in fiscal year 1998, about $57
million for NSA was received from sources other than the federal government.
Most of these additional funds, $38 million, were given to 11 state WIC
agencies by their state governments. Local governments provided most of the
remaining funds to local WIC agencies. While no good historical data exist
on the level of funding state and local governments have provided
specifically for NSA, USDA officials have found that the number of states
providing funds to the WIC program for nutrition services has declined. In
addition, those states that do provide funds have reduced the amount they
contribute. For example, in fiscal year 1992, 18 states made about $91
million in appropriated funds available for WIC, while in 2001, 13 states
made about $45 million available.

Some state and local agencies have sought additional funding for nutrition
services by accessing other sources of funding. California WIC, for
instance, has initiated the ?WIC Plus? program to assist local agencies
Nonfederal Support for NSA

May Have Decreased

Page 36 GAO- 02- 142 WIC Challenges

interested in obtaining additional funding from other sources, such as
reimbursements for nutrition services provided for WIC participants enrolled
in Medicaid. The New York WIC program is currently formalizing an agreement
with the state?s TANF program to obtain funding for providing additional
nutrition services for WIC participants enrolled in TANF.

However, the extent to which WIC agencies rely on other types of
contributions has diminished. Historically, WIC agencies have made use of a
variety of nonprogram resources, typically in- kind contributions such as
donated space, to cover some of the costs of WIC?s nutrition services and
program administration. But, according to the California WIC director, the
time and resources needed to apply for and administer additional funding,
such as foundation grants, can prevent WIC agencies from seeking additional
funding. A 1988 USDA study found that at 16 local agencies, the share of
costs covered by such nonprogram resources was substantial- 54 cents for
every program dollar. 49 However, our recent work at six agencies found the
share of costs covered by such resources to be much lower, ranging from 2
cents to 20 cents for every program dollar.

According to state and local WIC officials, responding to the increased
demands placed on the program using existing resources has required actions,
such as changes in service delivery and cost cutting, that may lower the
quality of WIC services. Almost 40 percent of the local agencies responding
to our survey reported that additional federal requirements have resulted in
a decrease in the average amount of time spent providing nutrition services.
State and local officials repeatedly raised the concern that the additional
demands cut into the limited time available to provide nutrition education
and counseling. According to one program expert, even the infant formula
rebate requirement can cut into nutrition education because staff must take
time to explain how the rebate works and what products are eligible.

According to the executive director of the National Association of WIC
Directors, balancing increased program demands and available resources has
forced some WIC agencies to cut costs by not increasing office space,
personnel, and information technology in response to increasing needs. The
1998 USDA survey suggests that the negative consequences of such

49 Abt Associates, Inc., Synthesis of Case Study Findings in the WIC
Program, Food and Nutrition Service, USDA: Alexandria, VA, Dec. 1988.
Balancing Increased Demands

and Available Resources Can Compromise Service Quality

Page 37 GAO- 02- 142 WIC Challenges

cost cutting may be extensive. 50 According to that study, 22 percent of
local agencies, serving almost 25 percent of all WIC participants, reported
having inadequate office space. Additionally, 30 percent of local agencies
serving about 41 percent of all WIC participants reported having
insufficient numbers of professional staff. Finally, as reported earlier, 56
percent of state WIC agency automated management information systems were
not capable of performing, or efficiently performing, 1 or more of 19
essential program tasks.

We identified 16 approaches that could be considered to address 1 or more of
the 6 major challenges facing the program. The approaches were identified
based on the following assumptions: (1) WIC will continue to be administered
by USDA, (2) income eligibility requirements will remain relatively
unchanged, and (3) the program will continue to operate as a discretionary
grant program. Each addresses a specific aspect of one or more of the six
major challenges facing the program. For example, four of the approaches
focus on funding; four relate to performance or impact measurement; three
address staffing issues; three relate to information technology; and two
relate to the provision of nutrition services. Most of the approaches also
address other problems, even if tangentially. Table 2 shows the challenges
we think each approach can help address. While each of the approaches offer
certain advantages, they also have potential negative consequences that
policymakers should consider.

During our work, we encountered other potential approaches in addition to
the 16 we selected; however, we focused on those that most directly
addressed the major challenges we identified. Our assumptions precluded some
approaches, such as moving the administration of WIC from USDA to HHS,
changing the program?s income eligibility requirements to target lower
income individuals, and making WIC an entitlement program. Such approaches
may warrant further study.

A more detailed description of the approaches- including potential
implementation strategies, a description of the rationale for considering
each approach, and possible advantages and disadvantages- is provided in
appendix III.

50 Abt Associates, Inc., WIC Participant and Program Characteristics 1998,
Food and Nutrition Service, USDA: Alexandria, VA, WIC- 00- PC, May 2000.
Approaches to

Addressing WIC Challenges

Page 38 GAO- 02- 142 WIC Challenges

Table 2: Sixteen Approaches to Addressing WIC Challenges Challenge Area

Approach Health and

welfare delivery changes Participant

changes Maintaining skilled staff Information

technology Assessing services Meeting

requirements

Make WIC services more accessible to applicants and participants by
increasing the variety of service providers.

X X X Improve WIC?s ability to respond to new health issues, such as obesity
and diabetes, and to participants? nutritional needs by expanding the range
and scope of nutrition education.

X XX X Assess the staffing needs of the state and local WIC agencies and
develop strategies to address any shortcomings.

X X Establish more stringent professional staffing requirements for local
WIC agencies.

X X Establish minimum continuing education requirements for WIC staff in the
areas of nutrition, breastfeeding promotion, and counseling.

X Expedite the components of WIC?s 5 Year Technology Plan related to (a) the
development of a model management information system and (b) the
facilitation the multistate acquisition of management information systems.

X XX Ensure that all local WIC agencies have direct Internet access. X
Implement nationwide EBT for WIC food benefits. X Develop and track national
outcome measures for nutrition services and program coordination and
integration.

X Require each state WIC agency to develop measurable goals that address
state- specific issues and track progress toward meeting these goals.

X Collect more data relating to WIC participants and program interventions
by expanding the CDC Pediatric and Pregnancy Nutrition Surveillance Systems.

X Develop a strategic plan to evaluate the impact of WIC?s nutrition
services. X Provide states with greater flexibility to convert food funds
into NSA funding. X XXXXX

Page 39 GAO- 02- 142 WIC Challenges

Challenge Area Approach

Health and welfare delivery changes Participant

changes Maintaining skilled staff Information

technology Assessing services Meeting

requirements

Increase the level of federal funding for WIC NSA. X XXXXX Increase overall
state contributions to WIC NSA. X XXXXX Increase the level of WIC funding
from other sources. X XXXXX

Source: GAO?s analysis.

The WIC program is facing serious challenges in its efforts to deliver
highquality nutrition services. Changes in WIC?s service environment and
additional requirements are causing the program to strain to provide
effective nutrition services. Program stress will likely increase in the
future because the program is considered a major point of access to health
services for low- income infants and preschool children, creating the
expectation that the program can do even more to help address emerging
health issues in this population.

In 2002, the Congress, through the reauthorization process, will begin to
make decisions that could fundamentally affect the program?s ability to meet
the challenges it faces in the delivery of nutrition services. In essence,
the Congress will be reexamining its expectations for the program and the
resources needed to meet those expectations. In describing the major
challenges facing the program and approaches that could help to address the
challenges, this report provides a structure for carrying out that
reexamination. Most of the approaches could involve basic changes in program
structure or the way nutrition services are funded. Decisions to adopt such
approaches- whether in part or in whole- ultimately rest with the Congress.
However, in regard to two of the approaches- recruiting and keeping a
skilled staff and assessing the effects of nutrition services - the Congress
lacks some information that would benefit decisionmaking.

In order to help the Congress and USDA identify strategies to address the
program?s challenges in recruiting and retaining a skilled staff and
assessing the effects of nutrition services, we recommend that the Secretary
of Agriculture direct the Administrator of the Food and Nutrition Service to
take the following actions: Conclusions

Recommendations for Executive Action

Page 40 GAO- 02- 142 WIC Challenges

 Work with Economic Research Service and the National Association of WIC
Directors to conduct an assessment of the staffing needs of state and local
WIC agencies. This assessment should examine factors such as staffing
patterns, vacancies, salaries, benefits, duties, turnover, and retention.

 Work with the Economic Research Service, the National Association of WIC
Directors, and other stakeholders, including the CDC, to develop a strategic
plan to evaluate the impacts of specific WIC nutrition services. This plan
should include information on the types of research that could be done to
evaluate the impacts of specific nutrition services as well as the data and
the financial resources that would be needed to conduct such research.

We provided a draft of this report to USDA?s Food and Nutrition Service for
review and comment. We met with Food and Nutrition Service officials,
including the Acting Administrator. The agency officials generally agreed
with the report?s findings and recommendations. The officials also provided
some technical changes and clarifications to the report, which we
incorporated as appropriate.

We are sending copies of this report to the appropriate congressional
committees; interested Members of the Congress; the Secretary of
Agriculture; the Director, Office of Management and Budget; and other
interested parties. We will also make copies available to others upon
request.

If you or your staff have any questions about this report, please contact me
or Thomas E. Slomba at (202) 512- 7215. Key contributors to this report are
listed in appendix IV.

Robert E. Robertson Director, Employment, Workforce, and

Income Security Issues Agency Comments

and Our Response

Appendix I: Stakeholders Providing Comments on Proposed Approaches for
Overcoming Challenges Facing WIC

Page 41 GAO- 02- 142 WIC Challenges

American Dietetic Association c/ o Arizona Department of Health Services
Phoenix, AZ

American Enterprise Institute Washington, D. C.

WIC/ Supplemental Nutrition Branch California Department of Health Services
Sacramento, CA

Center on Budget and Policy Priorities Washington, D. C.

Department of Health and Human Services City of Long Beach Long Beach, CA

Food Research and Action Committee Washington, D. C.

Food Marketing Institute Washington, D. C.

Gallatin City- County Health Department Bozeman, MT

National Advisory Council on Maternal, Infant & Fetal Health c/ o United
Health Centers of San Joaquin Valley, Inc. Parlier, CA

National Association of WIC Directors Washington, D. C.

Maternal Child Health Grady Health System Atlanta, GA

Minnesota Department of Health St. Paul, MN Appendix I: Stakeholders
Providing

Comments on Proposed Approaches for Overcoming Challenges Facing WIC

Appendix I: Stakeholders Providing Comments on Proposed Approaches for
Overcoming Challenges Facing WIC

Page 42 GAO- 02- 142 WIC Challenges

Montana Department of Public Health and Human Services Helena, MT

Pennsylvania Department of Health Harrisburg, PA

Zuni WIC Program Pueblo of Zuni, N. M.

Economic Research Service U. S. Department of Agriculture Alexandria, VA

Food and Nutrition Service U. S. Department of Agriculture Alexandria, VA

Office of Budget and Policy Analysis U. S. Department of Agriculture
Washington, D. C.

Administration for Children and Families U. S. Department of Health and
Human Services Washington, D. C.

Centers for Disease Control and Prevention U. S. Department of Health and
Human Services Atlanta, GA

Health Resources and Services Administration U. S. Department of Health and
Human Services Rockville, MD

Appendix II: Program Tasks Identified by USDA

Page 43 GAO- 02- 142 WIC Challenges

This appendix describes the 19 essential program tasks, identified by USDA,
that a WIC automated management information system should be able to perform
in order for program operations to be efficient.

Table 3: Automated Function Descriptions Function Description

Certification periods The system automatically calculates the date the
certification is due to expire for each participant. The system does this by
adding the appropriate number of days to the certification date that is
captured in the system during certification. Nutritional risk and priority
status Based on the nutrition and health information entered into the system
by the certifying

official and the priority system established by program regulations, the
system assigns the participant a nutritional risk code and assigns a
priority level. Where multiple risk factors exist, the system stores risk
factors for each participant and assigns the highest applicable priority. At
the state agency?s discretion, the certifying official may override the code
generated by the system. Income eligibility Based on the information
provided by applicants and established income eligibility

guidelines, the system calculates the applicant?s income and flags
individuals whose income exceeds program standards. For those determined to
be eligible, the system automatically stores the information in the
participant?s certification record. Where the applicant is determined
eligible based on adjunctive income eligibility, this information is also
stored on the system. Associate family members Clinic staff enter
information that applies to all family members into the system only

once. The system automatically updates or modifies the participant records
of all associated family members by linking the common family identification
number. The family identification number is used to facilitate coordination
of certification periods for family members, transferring families within
the system, and food package tailoring when several family members are
eligible to receive the full package. In addition, the system allows the
user to print all of the food instruments for all members within a family
when the parent or guardian is present for pickup. This is possible because
the system is programmed to associate all family members with a family group
identification number. Upon command, the computer sorts the WIC food checks
by family, grouping them for each individual within the family, and prints
those checks associated with the family when they are present for pickup.
Transfer of certification The system enables local staff to easily transfer
the participant from one agency to

another. To facilitate transfers within the state, the system maintains
statewide data on all certified participants. The staff at the participant?s
new location are able to access the participant?s file to find out what
foods were issued at the former local agency and when they were last issued
as well as other information useful in providing continued health and
nutrition- related services. Electronic certification data Transmission
Participant certification data is sent to the central computer facility
electronically either

in real time or batched mode. Paper forms are not sent through the mail.
Track nutrition education contacts and topics covered The system captures
the nutrition education provided to each program participant

throughout the certification period as well as nutrition education topic
covered during nutrition education training. Create food prescriptions The
system supports this function by allowing the certifying official to select
a food

package for issuance to a participant from a table of standard, pre- defined
packages. However, the certifying official has the flexibility to alter a
standard package or develop a new package from scratch by quickly selecting
food items from tables to construct the package. The system is programmed
with edits that prevent the user from issuing foods that are disallowed or
quantities of food that exceed the regulatory limit based on participant
category.

Appendix II: Program Tasks Identified by USDA

Appendix II: Program Tasks Identified by USDA

Page 44 GAO- 02- 142 WIC Challenges

Function Description

Issue benefits on demand Printing is done for each participant at the time
the participant is present to pick up the food instruments. With this system
there is no need fill out a food instrument by hand or to print any food
instruments in advance. The printing of food instruments on demand reflects
the most recent food package prescribed for the participant, and may include
adjustments to the food package recorded in the system before printing to
reflect late pick up of the instruments, as well as other anticipated
changes such as category change (i. e., infant to a child). This approach to
printing food checks is also used to reissue checks that are lost or stolen
from the client. Track referrals to other programs The system captures the
name of the programs to which the participant was referred. Perform
reconciliation Issuance information includes the name of the participant,
the participant?s identification

number, the food instrument serial number, the food package prescribed, the
date the food instrument was issued, the date the food instrument expires,
and the estimated value of the food instrument. Redeemed food instruments
are processed through regular banking channels or through the state payment
system for payment to the vendor?s account. Each food instrument redeemed is
matched with the issuance data maintained in the system, and a monthly
report is produced that shows a summary of the disposition of food
instruments and expenditures. Dual participation reporting The local worker
has access to statewide data to determine whether a duplicate record

exists on an individual who is newly certified for WIC. In an on- line
system, the information is available immediately. In a distributed system,
preliminary demographic data are recorded in the system. The information is
matched against the database periodically to identify clinics where the
applicant may already be participating. Where two separate state agencies
operate within a state (e. g., a geographic state agency and an Indian
tribal organization), the system produces a data tape or an electronic file
for exchange. One or both of the state agencies involved perform a
participant data match. This information is used to flag possible instances
of dual participation for follow- up action. Integrity profile The WIC
system produces report data in accordance with existing specifications and

produces other vendor management reports deemed necessary by the state
agency. Rebate billing reports Based on redemption data, the system produces
a report that determines the number of

cans of formula redeemed by brand name and by type, and the month the food
instrument was valid for participant use. In addition, the number of full
versus partial infant formula packages can be identified. The system also
provides rebate- billing reports for rebated foods other than formula.
Participation reports The system produces reports that summarize the number
of participants served during

a specified time period and for a specified area. This information is used
for caseload management and funds management. Participation characteristics
data sets The system produces a data tape for use in the biennial report to
the Congress on WIC

program and participant characteristics. Identify redeeming vendors The
system is designed to accept basic transaction information pertaining to
each

authorized retailer either at the time of issuance or at the time of
payment. Transactions are related to the vendor performing the redemption.
High- Risk vendor detection system The system supports this function by
flagging high- risk vendors based on suspicious

redemption patterns. Price editing for excessive charges The system assigns
a maximum value for each food instrument type. Once the food

instrument is redeemed, the system automatically checks the redeemed price
against the maximum value and rejects any food instruments exceeding the
maximum amount.

Source: Planning for WIC?s Future Technology Needs, Food and Nutrition
Service, USDA: Alexandria, VA, Mar. 2001.

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 45 GAO- 02- 142 WIC Challenges

1. Make WIC services more accessible to applicants and participants by
increasing the variety of service providers.

This could be accomplished by the following:

 Change legislation to allow the states to use demonstration projects to
test and evaluate the use of for- profit entities, such as health
maintenance organizations, as local WIC agencies. 1

 Encourage or require state agencies to give a greater preference
(consideration) to local agency applicants that provide a greater proportion
of services (1) during evening or weekend hours, (2) at more convenient
locations, and (3) in the native language of applicants or participants.

Rationale. WIC was designed to serve poor and low- income women and children
as an adjunct to good health care; therefore, it should be highly accessible
to this population. Service delivery by WIC agencies has become more
difficult due to changing health and social services delivery systems and
changing characteristics of the population served by the WIC program. By
having greater variety of providers and service locations, applicants or
participants may have greater access to WIC services.

Potential advantages of this approach include the following:

 Participation among working families and students may increase.

 At- risk individuals who do not have access to traditional clinics may be
reached.

 Partnerships with other community organizations may be formed, reducing
the funding required to support multiple locations.

 Additional providers may create a more competitive market for WIC
services, improving customer service.

 The local WIC program may receive added exposure in the community,
improving its ability to attract potential participants.

1 According to USDA?s response, state agencies have the option to establish
policy that permits for- profit entities to provide WIC clinic services
(including intake, certification, and food instrument issuance). The state
and/ or local agencies must remain fully accountable for regulatory
compliance by for- profit entities selected to serve as WIC clinics, and
these entities must operate the program in a nonprofit manner. A written
agreement or contract that clearly delineates that entity?s WIC
responsibilities and obligations is essential to compliance. Appendix III:
Approaches to Overcoming

Challenges Facing WIC

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 46 GAO- 02- 142 WIC Challenges

Potential disadvantages of this approach include the following:

 Authorized grocery store vendors that are allowed to provide space could
compromise the independence of the state and local agencies in their vendor
management roles and create the appearance of a conflict of interest.

 The integration of WIC with health services may be more difficult if WIC
is operated at alternative locations, such as grocery stores.

 Inconsistent and inaccurate information may be provided at alternative
locations, resulting in a lack of program continuity and standardization.

 Staff members who are bilingual or willing to work evening and weekend
hours or in low- income neighborhoods due to safety concerns are difficult
to find.

 Few new agencies are applying to be WIC providers.

 WIC applicants, participants, staff and others may get confused about
service delivery if multiple WIC providers exist without defined service
boundaries.

2. Improve WIC?s ability to respond to emerging health issues, such as
obesity and diabetes, and to participants? nutritional needs by expanding
the range and scope of nutrition education.

This could be accomplished by the following:

 Expand nutrition education and breastfeeding promotion curricula to
include such topics as the benefits of physical activity and influence of
media advertising on the food preferences of parents and children.

 Place greater emphasis during educational sessions on participants?
eating, feeding, and shopping practices or behaviors.

 Increase the use of multiple strategies when counseling participants.

 Provide more age- appropriate nutrition education to preschool- age WIC
participants.

Rationale. Over the past decade, the incidence of obesity and diabetes among
adults and children has reached epidemic proportions, especially among lower
income individuals. The nutrition education and breastfeeding promotion
sessions provide an opportunity for WIC staff to help participants prevent
these diseases. However, we observed that the quality of the nutrition
education to WIC participants varied significantly. Experts indicate that
nutrition counseling that addresses eating behaviors and/ or that uses
variety of teaching strategies can be more effective in preventing obesity
and other nutrition- related illnesses.

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 47 GAO- 02- 142 WIC Challenges

Potential advantages of this approach include the following:

 Disease prevention may be less costly than treatment.

 Increased participant interest in nutrition classes may result in
increased knowledge and application to daily life, leading to better health.

 Training professional staff to provide information on emerging health
issues may improve image of WIC staff.

 Impressionable preschool children may be taught positive messages that can
shape lifelong nutrition and health choices and help them influence parents
and caregivers.

 Job satisfaction for registered dietitians, able to utilize more advanced
skills, may improve.

Potential disadvantages of this approach include the following:

 Suggested strategies may require longer WIC appointments and participants
may be too tired, busy, or stressed to take advantage of the education.

 Too little research exists to determine most effective strategies.

 Staff members lack expertise and training on various topics outside of
basic nutrition.

 Better nutrition education and breastfeeding promotion will require
additional staffing and resources at the local agency level.

 Parents may be inconvenienced by making pre- school children available for
education because, with more parents working, children are infrequently at
WIC sites.

3. Assess the staffing needs of the state and local WIC agencies and develop
strategies to address any shortcomings.

This could be accomplished by the following:

 Conduct a national study to examine staff distribution, duties,
recruitment, retention, and job satisfaction.

 USDA working with its partners- such as state WIC agencies, HHS, and NAWD-
to develop and implement agreed upon strategies.

Rationale. Relatively little national data are available on the size and
composition of WIC staff. However, indications from USDA surveys suggest
that local WIC agencies are having difficulty recruiting and retaining
professional staff. Because of the lack of national data, little is known
about the exact nature of the staffing problems.

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 48 GAO- 02- 142 WIC Challenges

Potential advantages of this approach include the following:

 The opportunity may be created to define completely what tasks WIC should
be undertaking at the various staffing levels, the level of effort needed,
and the appropriate distribution of duties among various types of staff.

 Information may provide an objective basis for funding requests.

 The image associated with working for the WIC program among nutrition
professionals may be improved, along with staff retention.

 The quality of nutrition services may be improved. Potential disadvantages
of this approach include the following:

 National data may not take into account the variations in state and local
agency regulations or local job markets and may be difficult to interpret
for local agencies.

 Limiting the study to current staffing and duties, without first defining
the tasks that WIC must complete to achieve the results the program is
intended to achieve, would not be as valuable to improving services.

 Additional resources are needed to assess and address staffing needs.

 Some factors affecting staffing are independent of USDA. 4. Establish more
stringent professional staffing requirements for

local WIC agencies.

This could be accomplished by the following:

 Develop an ideal ?staffing plan? based on the number of participants per
agency. Such a plan would identify the types of duties performed by
professional, paraprofessional and support staff to make the most effective
and efficient use of available resources. Establish standards for staff- to-
participant ratios, including the number of dietitians, nutritionists, or
lactation specialists an agency should employ, or have access to, based on
its number of participants.

Rationale. No requirement exists that local WIC agencies employ a dietitian,
nutritionist, or lactation specialist or that their staff members have
access to the services of these professionals. We observed that the
availability of nutrition professionals who had sufficient time to provide
individual counseling varied from agency to agency, resulting in a range of
the quality of services provided. Without staffing requirements to ensure a
minimum level of access to professional nutrition services, local agencies

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 49 GAO- 02- 142 WIC Challenges

may not be able to provide adequate services, especially to high- risk
participants.

Potential advantages of this approach include the following:

 Proper staffing may increase participant satisfaction.

 Quality of services may be improved.

 Job satisfaction may be increased by clearly describing responsibilities
for various staff members.

 The program may be better able to respond to emerging health issues.

 Funds needed to provide high- quality services may be more easily
estimated.

Potential disadvantages of this approach include the following:

 NSA funding may need to be increased.

 Research is needed to determine what constitutes an ?ideal staffing plan?
and the tasks required by each occupation.

 The availability of professional staff may be limited in some areas.

 Staffing ratio needs to be based on the nutritional status of
participants, rather than the number of participants.

 Legislative changes to the program may be needed.

 If standards focus on professionals, the role of paraprofessionals may be
diminished.

5. Establish minimum continuing education requirements for WIC staff in the
areas of nutrition, breastfeeding promotion, and counseling.

This could be accomplished by the following:

 Develop national training requirements for WIC service providers, both
professional and support staff, with input from WIC- related professional
associations and appropriate federal agencies, such as CDC.

 Require states to establish continuing education requirements for their
WIC agencies.

Rationale. Currently, WIC staff are not required to continue their
education, despite the fact that knowledge in the health and nutrition
fields has evolved. Recent nutrition research has provided new information
on diets to prevent illness, on innovations in nutrition counseling, and on
new nutrition- related health concerns, such as the

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 50 GAO- 02- 142 WIC Challenges

epidemic rise in obesity. Requiring all WIC staff to receive continuing
education, even those not required to meet professional certification and
licensing requirements, could improve the quality of WIC services and
enhance the professionalism of WIC staff.

Potential advantages of this approach include the following:

 The qualifications of WIC staff may improve.

 Staff retention and job satisfaction may be increased.

 The quality of nutrition services may be improved and the amount of
misinformation provided to WIC participants may be decreased.

 Training could be more focused on program needs, not just on individuals?
interests

Potential disadvantages of this approach include the following:

 Additional NSA resources are needed to implement training and continuing
education requirements.

 It is unlikely that a universal plan could be devised to fit the wide
range of availability of staff, costs and client needs at the local
agencies.

 Training requirements may discourage employment in WIC if time and expense
is to be assumed by employees.

 Reporting requirements may be increased at the state and local agencies to
ensure compliance.

6. Expedite the implementation components of WIC?s 5- Year Technology Plan
related to the development of a model management information system and the
facilitation of multistate acquisitions of management information systems.

This could be accomplished by the following:

 USDA could prepare a report for the Congress in the next 2 years that
outlines the features of a model system, the legislative and regulatory
changes required to facilitate multistate acquisitions, and the associated
funding needs.

Rationale. USDA has identified 19 essential program tasks that WIC
management information systems should be able to perform, such as
participant certification, benefit delivery, vendor management, and funds
management. Some of these tasks are currently beyond the capability of over
half of the state agencies. USDA has also noted that about 60 percent of
state systems have exceeded or will exceed their life cycles within 3

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Page 51 GAO- 02- 142 WIC Challenges

years. A model management information system and the facilitation, through
state partnerships, of the acquisition of management information systems
have the potential to accelerate the upgrade of state systems and promote
greater standardization of needed program data.

Potential advantages of this approach include the following:

 The multistate purchase of equipment and services for new systems and/ or
upgrades may reduce administrative burdens for individual states, lower
costs and save time, and accelerate the acquisition of system enhancements
for some states.

 Greater consistency and standardization may occur in WIC assessments and
service delivery.

 Program participation in CDC?s pediatric and pregnancy nutrition
surveillance systems may be improved.

 Program fraud may be decreased nationwide.

 Collaborative, nationwide technical standards may be created that could
facilitate program communications, including the transfer and sharing of
data.

Potential disadvantages of this approach include the following:

 State legislative and regulatory barriers may discourage multistate
purchases of equipment and services.

 Sources of additional funds needed for development of standards and for
implementation of the systems are uncertain.

 A system that has the flexibility to accommodate a wide range of
statespecific requirements and applications will be difficult and expensive
to create.

 USDA may not have the technical expertise necessary to develop a model
management information system.

 Very often when model systems are developed, by the time they are
completed, technology and program requirements have evolved sufficiently to
render the model less useful than anticipated.

7. Ensure that all local WIC agencies have direct Internet access.

This could be accomplished by the following:

 Set a target date for state WIC agencies to ensure that all local agencies
have direct access to the Internet.

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Page 52 GAO- 02- 142 WIC Challenges

Rationale. The Internet can be used by federal, state, and local agencies
for a variety of purposes related to the WIC program. USDA uses the Internet
to provide state and local WIC agencies with program information, such as
eligibility guidelines, application instructions, program funding,
participation rates, and current law and regulations. Yet, available
information indicates that hundreds of local agencies lack direct Internet
access. The lack of Internet access may be due to several factors, such as
the availability of telephone lines and local Internet providers. The
quality of WIC services could be improved by enabling all local WIC
professionals to efficiently communicate directly with USDA, other WIC
agencies, and nutrition or health experts via the Internet.

Potential advantages of this approach include the following:

 Local agency websites for communicating program access information may
increase WIC participation.

 Nutrition education materials may be made more accessible.

 WIC staff may be given the option of distance learning and self- paced
training opportunities.

 Nutrition, health, professional, and other information may be made more
accessible, especially to remote locations.

 Staff effectiveness may greatly improve.

 Communication and reporting between federal, state, and local agencies may
be facilitated.

 The Internet may help WIC staff to locate potential sources of financial
support.

Potential disadvantages of this approach include the following:

 Added expense of hardware/ software and Internet service may not be
covered by state funding requiring the use of limited nutrition services and
administrative funds.

 Internet expense may not be justified by its impact on program operations.

 Potential exists for abuse by WIC staff.

 Computer systems and participant records may be vulnerable to viruses or
hackers.

8. Implement nationwide electronic benefit transfers for WIC food benefits.

This could be accomplished by the following:

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 53 GAO- 02- 142 WIC Challenges

 Set a target date for implementation of EBT systems.

 Test and evaluate a variety of EBT systems- such as smart card, magnetic
strip, and Web- based technologies.

 Develop key infrastructure elements, such as a database of WICspecific
universal product codes, to support the implementation of EBT systems.

Rationale. WIC participants typically receive paper vouchers or checks to
purchase specific foods prescribed by WIC staff. The grocery industry
reports that transactions involving these vouchers or checks incur
comparatively high costs. USDA and the WIC retail community have established
goals to reduce the transaction costs for grocers and improve the buying
experience for WIC participants. An EBT system has the potential to help WIC
meet these goals, but the infrastructure is not yet in place to support
these systems.

Potential advantages of this approach include the following:

 The timeliness and accuracy of financial transactions may be increased.

 Program fraud and abuse may be minimized.

 Paper use associated with voucher printing, storage, collection, and
destruction may be reduced.

 Stigma associated with the paper transaction process may be diminished.

 Interstate transfer of participant certification may be facilitated.

 Opportunities to integrate the delivery of WIC and other services may be
expanded.

 Lost or stolen EBT cards are more easily replaced.

 Food items may be more easily purchased as needed.

 Ability to monitor and collect information on products purchased may be
increased.

Potential disadvantages of this approach include the following:

 Development and operational costs of EBT, particularly for small food
retailers, could present a financial hardship that may decrease the number
of stores that wish to participate in WIC.

 Mandating an implementation date for EBT does not suddenly imbue WIC
clinics and state agencies with the interest and the technical understanding
necessary to implement EBT.

 EBT infrastructure at the retail level, especially in rural areas, is not
available to meet program needs.

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 54 GAO- 02- 142 WIC Challenges

 No commercial model of EBT exists.

 Development and timely updating of a national system of specific
WICapproved food product codes necessary for the operation of an EBT system
could be difficult, especially for states that use a ?lowest price? policy
where products allowed by WIC can change from store to store or from day to
day.

9. Develop and track national outcome measures for nutrition services and
program coordination and integration.

This could be accomplished by the following:

 USDA working with its partners- such as state WIC agencies, HHS, and NAWD-
to develop outcome measures.

 Draw outcome measures from CDC?s pediatric and pregnancy surveillance
systems (see approach #11).

 Drawing outcome measures from HHS? Healthy People 2010 objectives.

 Track the measures at the state and national levels.

 Report annual progress of achieving goals in a manner similar to that in
the Web- based Maternal and Child Health Program information system.

Rationale. In response to the Government Performance and Results Act of
1993, USDA has attempted to develop national outcome measures for some of
WIC?s nutrition services. However, it has had very limited success
establishing these measures because of resource constraints and difficulty
identifying data. Moreover, USDA relies on the state and local agencies, as
grant and subgrant recipients, to provide the services to help accomplish
the program?s goals and objectives. USDA currently requires state agencies
to annually describe their goals and objectives for improving program
operations, but it does not require that the state goals be consistent with
any of the national goals or objectives. Developing some outcome measures
that assess the coordination and integration of WIC services with other
health or social service providers would highlight the federallevel
objective to provide more consistent care to participants and reduce
duplicative activities.

Potential advantages of this approach include the following:

 Data and information would be more available for future studies.

 Using the HHS Healthy People 2010 objectives is an excellent way to
achieve consistency with coordinating agencies and programs.

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Page 55 GAO- 02- 142 WIC Challenges

 If WIC caseworkers focused on key objectives, clearer progress could be
made, which would help the program justify funding from the Congress and
state legislatures.

 Successful outcomes may lead to the identification and implementation of
best practices.

 Accountability of state and local agencies may be increased, reducing the
need for state and local site visits and monitoring.

Potential disadvantages of this approach include the following:

 The CDC?s surveillance systems have significant limitations, including
voluntary participation.

 Some jurisdictions might feel pressured to drop local priorities for
national ones if outcome measures were defined the same for all
jurisdictions.

 Different states, regions, and counties use different computer systems and
coding schemes to record WIC data, making it difficult to compile data
nationally or even statewide.

 Outcomes measured may be partially attributable to other programs or
services, not just to WIC services.

 Focus on a limited set of outcomes may prompt programs to address outcomes
that are easily measurable to the exclusion of others.

10. Require each state WIC agency to develop measurable goals that address
state- specific issues and track progress toward meeting these goals.

This could be accomplished by the following:

 USDA and state agencies work as partners to develop state level measurable
goals.

 Goals should be based on state health issues identified with CDC?s
pregnancy and pediatric surveillance systems and other systems.

 Goals should relate to quality of services- such as participant retention
(particularly for children) and referral outcomes- in a way that can be
quantified.

 Provide training or technical assistance to state agency staff in
developing goals and objectives under the Government Performance and Results
Act.

 Enhance state and local management information systems to support tracking
goals (see approach #6).

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 56 GAO- 02- 142 WIC Challenges

Rationale. While USDA currently requires state agencies to describe their
goals for improving program operations on an annual basis, the agency does
not require that the goals be measurable. As previously described, about
half of the state goals and objectives that we reviewed lacked key elements,
such as baseline or target values, needed to measure progress. Using more
measurable goals would enable WIC to demonstrate progress at the state
level.

Potential advantages of this approach include the following:

 A focus on these measurable goals and objectives would help clinic staff
nationwide focus on the common purpose of WIC without requiring agencies to
employ the same strategies.

 Measurable goals may lead to more focused, meaningful state WIC plans.

 State and local agencies may be encouraged to focus on outcome goals
rather than caseload.

 The ability to demonstrate and measure program effectiveness may support
funding requests.

Potential disadvantages of this approach include the following:

 This approach does not take into account the differences in state
operations and, more importantly, the differences in the type and degree of
action required to improve program effectiveness for different states or
regions.

 Data may not be available or reliable for identifying baselines or
appropriate targets, or for monitoring progress.

 State agencies will require training to develop measurable goals.

 Attainment of some goals may also be dependent on other health programs.

11. Collect more data relating to WIC participants and program interventions
by expanding the CDC pediatric and pregnancy nutrition surveillance systems.

This could be accomplished by the following:

 USDA works with its partners- such as HHS, state WIC agencies, and NAWD-
to find ways for WIC to obtain more information from the pediatric and
pregnancy nutrition surveillance systems.

 Increase the number of states and federal programs participating in
pediatric and pregnancy nutrition surveillance systems.

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Page 57 GAO- 02- 142 WIC Challenges

 Increase the number of variables collected by the pediatric and pregnancy
nutrition surveillance systems, to include data such as type of WIC
nutrition interventions received and household socioeconomic status.

Rationale. CDC?s pediatric and pregnancy nutrition surveillance systems
track the health status of children and the risk factors of mothers who
participate in selected federal programs. While data for WIC participants
represent a substantial portion of the sample, not every state WIC agency
participates. Moreover, the systems do not track individuals over time or
collect information on the types of services that individual participants
receive. Expanding the data collection associated with these systems would
enable WIC to better track program performance and provide critical data
needed to evaluate the effectiveness of WIC services.

Potential advantages of this approach include the following:

 Data collection systems, such as CDC?s pediatric and pregnancy nutrition
surveillance systems, may be an effective approach to improving the amount,
national representation, and usefulness of data collected.

 Improved data may help justify funding and help ensure that it is targeted
to treatments most likely to yield successes.

 Enhanced data systems may provide more relevant data for program planning,
monitoring, and evaluation. With all states participating, the usefulness of
the data collected is increased.

 Expansion and enhancement of an existing system may be less costly than
creating a new system.

Potential disadvantages of this approach include the following:

 Additional resources may be needed for automated systems and staff
training to enable some states to participate in CDC?s pediatric and
pregnancy nutrition surveillance systems.

 Much of the information in these systems is incomplete and contains many
errors, which raises concerns about accuracy.

 Significant costs are associated with expanding participation in the
surveillance systems, as well as increasing the number of variables in the
questionnaires.

 The variety of counseling topics, the sensitivity of health related
advice, and privacy concerns make nationwide data collection difficult.

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 58 GAO- 02- 142 WIC Challenges

12. Develop a strategic plan to evaluate the impact of WIC?s nutrition
services.

This could be accomplished by the following:

 Identify the research needed to determine the effects of WIC?s nutrition
service interventions on its participants.

 Identify necessary data and appropriate research methodologies.

 Identify resources required to conduct impact research. Rationale. USDA
currently spends about $ 1.1 billion annually for NSA. In recent years, USDA
has spent about $2 million to $3 million annually on WIC- related research.
Yet, few research findings exist on the effectiveness of specific nutrition
services. According to USDA officials, the money dedicated to research is
insufficient to assess the effect of WIC services on participants, in part
because of the need for primary data and the complex nature of the required
methodologies.

Potential advantages of this approach include the following:

 Well- designed evaluation/ research would make it possible to assess
program impact and determine appropriate changes.

 Studying the effects of different nutrition promotion treatments is
essential to helping WIC direct its nutrition promotion efforts to the
activities and approaches most likely to yield the best results.

 The identification of the type of research and the resources needed would
help to justify funding support required.

Potential disadvantages of this approach include the following:

 Assessing the effect of specific nutrition education interventions may be
difficult.

 Several obstacles exist to evaluating the impact of WIC?s nutrition
services. These include: participants not being required to attend nutrition
education, not having clear and well- defined outcomes, and adequate
assessment tools not being available for measuring dietary intake and
changes in dietary behavior.

 Research is difficult, time- consuming, and costly to conduct.

 Representative samples are difficult to gather from the different types of
WIC agencies throughout the United States.

 Implementing a strategic plan to evaluate the impact of WIC?s nutrition
services would require a reliable, significant ongoing commitment of funding
and staff resources.

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 59 GAO- 02- 142 WIC Challenges

13. Provide states with greater flexibility to convert food funds into NSA
funding.

This could be accomplished by the following:

 Change legislation to permit states to (1) carry converted funds forward
into subsequent years, (2) continually convert food funds resulting from
program savings into NSA funding for the purposes of serving more
participants, and/ or (3) target some food funds to support high- cost
nutrition service activities, such as home or hospital breastfeeding
support.

Rationale. Current program regulations allow states to convert food funds to
NSA funds to cover only current year expenditures that exceed their NSA
grants under two conditions: (1) A state has an approved plan for food cost
containment and for increases in participation levels above the USDA-
projected level and (2) a state?s participation actually increases above the
level projected by USDA. However, the increased participation supported by
the converted funds is not considered in the allocation for the next year.
Officials from several state WIC programs and NAWD have indicated that the
current conversion policies do not provide any incentives for states to
aggressively pursue food cost containment strategies for the purposes of
increasing participation. In recognition of the high costs associated with
delivering nutrition services to some participants, recent legislation, P.
L. 106- 224, permits a state- level agency serving remote Indian or Native
American villages to convert food funds to NSA funds to cover allowable
costs, without having an increase in participation.

Potential advantages of this approach include the following:

 Flexibility may serve as an incentive or reward for containing food costs.
For example, states may be more aggressive in using strategies to reduce
food costs, including educating participants to be better shoppers, if they
knew some of the money saved could be converted to NSA to improve nutrition
services.

 States may have more control over their program budget.

 Barriers that states claim prevent them from using current conversion
authority would be removed.

 Fund conversion for targeted purposes such as nutrition education,
breastfeeding promotion, and or outreach may increase participation.

Potential disadvantages of this approach include the following:

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 60 GAO- 02- 142 WIC Challenges

 Increased conversion could limit the number of participants served by the
program during times of growing caseloads and limited food funds.

 The quality of food packages provided to participants may suffer, which
may also reduce participation.

 The portion of federal funds spent on NSA, viewed by some as an

?administrative expense,? may be decreased, misrepresenting the funding
requirements of the program.

 Unless an evaluation requirement is created, the effects of providing
increased conversion authority would be unknown.

 Carrying forward converted funds into subsequent years could result in a
significant portion of funds remaining unused and rolled forward from year
to year.

14. Increase the level of federal funding for WIC NSA.

This could be accomplished by the following:

 Appropriate additional funds that increase the average grant per
participant.

 Provide additional funds that target specific needs, such as the
acquisition of management information systems.

Rationale. The federal grant level for NSA is based on the national average
of NSA grant expenditures that were made per participant per month in 1987,
adjusted for inflation. In fiscal year 2001, grant levels were based on a
national average of $12.27 per participant per month. Since the grant level
was established, new demands have been placed on the program in part because
of new program requirements, shifting demographics, emerging health needs,
and changes in the health care and social service environment. In addition,
our case studies suggest a decrease in the extent to which nonprogram
resources, such as in- kind contributions, are covering nutrition service
and administration costs.

Potential advantages of this approach include the following:

 The program may be better able to meet its responsibility as an adjunct to
other health care services, including immunizations.

 The program may be able to fully implement interventions that have been
demonstrated to improve immunizations among children enrolled in WIC.

 The program may be able to implement approaches to address challenges it
faces that have been identified above.

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 61 GAO- 02- 142 WIC Challenges

 The recruiting and retention of staff may be improved by offering higher
salaries and better benefits.

 Additional funds targeted for management information systems may help to
improve the efficiency of client services and program management.

 Additional funds targeted for EBT may improve program integrity and
streamline financial transactions and reporting.

 The program may be better able to adjust to changes in the characteristics
of the population it serves and the environment in which it operates.

 The program may be better able to carry out additional responsibilities
placed on it since 1987.

Potential disadvantages of this approach include the following:

 No guarantee exists that additional resources would improve outcomes.

 Additional funds for NSA would be perceived as reducing resources
available to provide food benefits to potential participants.

 More federal funds could reduce the likelihood of state financial support
of the program.

 Additional resources may be difficult to justify without specific
information about how much it costs to provide essential services and/ or
the cost- effectiveness of nutrition services.

15. Increase overall state contributions to WIC NSA.

This could be accomplished by the following:

 Change WIC funding guidelines to require or encourage a state match,
either monetary or in- kind, of some portion of WIC NSA funds.

 Ask states to provide a match for special purpose grants, such as
continuing education for WIC staff.

Rationale. State agencies rely almost entirely on their federal grants to
cover their WIC NSA costs. No state matching requirement exists for WIC-
although some states volunteer support for WIC. In responding to our 1999
survey of state- level WIC agencies, 11 state- level agencies reported
receiving state funds for WIC in fiscal year 1998. The state contributions
ranged from less than 1 percent to just over 37 percent of their total NSA
funds. Increasing the level of state contributions for WIC could help to
enhance the quality of nutrition services.

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 62 GAO- 02- 142 WIC Challenges

Potential advantages of this approach include the following:

 More resources may enhance WIC services; for example, more funding would
enable hiring more staff so more time could be spent on nutrition education
with participants.

 An increase in state funds may increase program flexibility. For example,
federal restrictions may not apply.

 State support and commitment to the program may be demonstrated with an
increase in state funds.

 States may have a greater incentive to be efficient.

 Additional funding sources would strengthen partnerships and program
services.

Potential disadvantages of this approach include the following:

 Federal funding may decline.

 States may divert funds from other public health programs.

 Some states may turn down federal funding, resulting in fewer resources
available for WIC services.

 Some states, including those with a disproportionate portion of lowincome
population, may not be able to afford a match.

 Tension may be created between federal and state goals for the program.

16. Increase the level of WIC funding from other sources.

This could be accomplished by the following:

 Help state and local agencies in the area of resource development.

 Provide incentives or funding to support state and local fundraising
efforts.

 Generate program- related income, such as from fees for nutrition
education or breastfeeding support to noneligible individuals or processing
vendor applications.

Rationale. State and local agencies use funding from other sources to
enhance WIC services. California WIC has initiated a ?WIC Plus? program to
identify and obtain other sources of funds for the purpose of enhancing
nutrition services. Also, the New York State WIC program is currently
formalizing an agreement with the state?s TANF program; under this
agreement, the TANF program would provide funds to WIC for additional
nutrition services to TANF program participants who are also enrolled in
WIC. However, based on our survey of local agencies, about 5 percent of

Appendix III: Approaches to Overcoming Challenges Facing WIC

Page 63 GAO- 02- 142 WIC Challenges

the funds received in fiscal year 1998 came from other sources. Obtaining
additional funding from other sources may help improve the quality of WIC
services.

Potential advantages of this approach include the following:

 Collaboration with other programs, such as TANF and Medicaid, may be
increased if other programs paid WIC to provide services to their
participants.

 Services may be enhanced and management information systems improved.

 Income from charging fees to non- WIC participants for some services may
enhance the image of WIC and improve the quality of services offered.

Potential disadvantages of this approach include the following:

 Not all WIC agencies are able or willing to pursue additional funding.

 Staff time and resources are needed to administer income- generating
efforts.

 Income could vary from year to year resulting in the variation of program
services.

Appendix IV: GAO Contacts and Staff Acknowledgments

Page 64 GAO- 02- 142 WIC Challenges

Thomas E. Slomba, (202) 512- 9910 Patricia F. Donahue, (202) 512- 6772

In addition to those named above, Peter M. Bramble, Jr.; Corinna A.
Nicolaou; Lynn M. Musser; Carolyn M. Boyce; Judy K. Hoovler; Clifford J.
Diehl; and Torey B. Silloway made key contributions to this report. Appendix
IV: GAO Contacts and Staff

Acknowledgments GAO Contacts Staff Acknowledgments

(130011)

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