DOCUMENT RESUME

ED 201 395 PS 012 137

TIILE

INSTITUTION

FEPORT NO

PUB DATE

NOTE

Better Health for Our Children: A National Stratecv.

The Report of the Select Panel for the Promotion zf

Child Health to the United States Congress and the

Secretary of Health and Human Services. Executive

Summary.

Public Health Service MEW), Rockville, Mi.

DRHS-PHS-79-55071

61

32p.; For other volumes of this report, see PS 012

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DESCRIPTORS *Administrator Role; *Children: Delivery Systems:

Financial Support; *Governmental Structure; *Heal:

Needs; Health Personnel: *Health Services: Life

Style; *National Programs: Nutrition; Organizati:.,:al

Effectiveness; Pregnancy: Research ,Needs

IDENTIFIERS Hazards

ABSTRACT

This executive summary presents specific proposals improve maternal and child health conditions in the United States.

Contents of the summary are organized in 13 chapters. Five overridin: concerns in the areas of health and health care are identified in

Chapter One. Chapter Two focuses on the reduction of environmental

risks; Chapter Three explores the relationships between health and

behavior: and Chapter Four identifies four ways to improve the

nutritional status of mothers and children. Chapter Five focuses

mainly on prevention services that typically can be delivers:1 through primary care systems. Chapter Six identifies nine organizational

attributes that should be incorporated into all provider arra...ngements

and submits proposals for strengthening existing arrangement=. Chapter Seven discusses home visiting, primary mental health care,

categorical services, mass screening, hospital care, and

regionalization. Chapters Eight and Nine concentrate on organizing

services for special populations and financing health services,

respectively. Chapter Ten suggests ways to improve program

coordination and management. Chapter Eleven discusses federal

administration arrangements. The final two chapters suggest neu roles

for and relationships among health professionals and list iomaLns of

special importance on which research is needed. In conclusion, three

sets of goals are formulated to clarify relationships among the many

recommendations zi.de. (Author/RH)

* * * * * * * * * * * * * * *'4 4******************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ReproductinnE supplied by EDRS are the best that can be made

from the original document. *************** ,,..z.4***************************************************
BE

FOR

U S DEPARTMPHTlr

EDUCATION

NATIONAL iNSTif.TE

EDUCATIsS,

5 DOC HAS tl( Old:ED S.AC T. AS (ECF

,HE PERSON OP OPC,4N,ZA" 41,NG O'' - SATED DO .)" E ScAP SEN F ONa,_ N Fou, A T OS rt.,. 0,,

HEALTh

PHIL

IA. STRATEGY

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or The Pr-,-)77cAtz

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To

States :long:7(

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Exec Sum .-na7

THE L. OF HEALTH AND FR. AN SERVICES

.blic HealW Servi,

Assistant 3ecretan. or Surgeon Genf:ral

-)) Publication No.
DEP ,RTVENT -EALTH D Ht.,, AN SERVIC=5

THE ..

:LEC- FOR THE "'HOT N CHILD

TREET. r . 711

t 136 202-634 -=TO;

December

lionora .. itr.1a

Secret:

Depart E. S,ervffees

Honorar,: .:ward

Chairma lbccminit: dn He :7h and Scient if ic: ,1,-search Senate ttee on at d-dman Rescorces

Honors A.

Chairm. .1 Envi rod :t House ._-- -it, on -,:r ;ir admmer _

Dear S. .:rr :man Waxmad. : a- 7.;111 the r :or: the 3elect Panel for th, Chf lice. 7. in 14-1't Pubi c Ls 95-626 lir::

T: 17 mc: Jars 3",:.1 and staff .devoted an extrauflinary dnou-- aergy anci--we sdom to task. 'Jur cc- r.t:_ se_ 'opus:- .,,- have all to take the e )1-7 . : Ihe mandd Congress assi --d . -.e c.tauce le -,:u-iat ion- na t onal e f f: e, (., has our 4ork wit 77.1 za-st. 7 fts is :ed :s mob: :ize the ..- of rondre7 :nd orge lizat ion hi cc en;af-ed i7 ways smal in Lind-- and se': Me tine ' ea: nce- this cour.: ry's ch. Ldr: : : arryi 1 and th-- at ion, arc- prof fundly th--::r were the and J.ivd of av t a len:, cornpet7-:- am7 , def:_ected ccomplishmerd. of a :reat va- o: ,1 a-ul privad- ts in communities t 2. also be tark1y aware of the extent )f :;- ; 1:-.-dale7d,.. :hat rem:, or record:-.endat ---ef Joy a 1,;,,:rdheaded of serious

um:, needs 1- chi:. . health, a rec-_-e:.1 tion of -1st successes and 'utur :7mo-JVI:un; 0,, for sftectiv eeting :hese nee .j;, carefu cons : 101,- ,.w.:dnesses ';trength; of current Feder __ pre: -. ' cc. :nd a .:nd pr: dno: ic assessment of :he cd : . -rovide ; 'rents, professionals, and 7.;.1" : id-_:rove lealth ts,1_,.-.1.1 the scientific, f . .:71ey

in
Honorable Patricia R. Harris

Honorable Edward M. Kennedy

Honorable Henry A. Waxman

Page Two

Volume I of our report presents our major findings and

recommendations.

'.olume II contains specific recommendations for improving five

major Federal programs with significant impact on child health:

Title V of the Social Security Act

The Special Supplemental Food Program for Women, Infants and

Children

P.L. 94-142: The Education for All Handicapped Children Act

Medicaid and EPSDT

Community Mental. Health Centers and Services Systems

Volume consists of what we believe to be the most

comprehensive compilation of data on child health in the U.S. yet

to he published.

We also submit a collection of background papers, listed at the

end e: Volume I, which were prepared for the Panel, and which we

believe will he extremely useful to those who wish to become

familiar in greater depth with selected aspects of the issues we

have -analyzed.

S me of our recommendations should be acted on immediately.

Other are designed to be considered and implemented over a period

of ye -t;. A11 of our recommendations are practical, and as

spe(:1 .c and concrete as we have been able to make them.

"I'o goals we set out encompass an extremely broad sweep of

issues. In accordance with our congressional mandate we have

addressed and analyzed issues and policies pertaining to the

physical environment, health behavior, health services organization

and financing, and health research. We did not try to go bejond

these, although we are fully aware that other aspects of the social

environment exercise a powerful influence on health. It is true

that if we could eliminate poverty and racism in this country, if

high quality preschool programs and'community supports for families

were more available, if teAchers and schools were more effective,

if we had full employment and every young person could look forward

to productive work, our health indicators would improve

significantly. Nevertheless, we have not focused on these issues,

both because they are outside th,! Panel's mandate, and because we

wish to help direct public attention to the extensive opportunities

to improve child health by improving health policies and programs.

iv
Honorable Patricia R. Harris

Honorable Edward M. Kennedy

Honorable Henry A. Waxman

Page Three

The Panel has asked .ne to call your attention to an .additional problem we faced in defining our mandate. Ac you know, the legislation that established the Panel asked us co look at the health of "children and expectant mothers." Child health is obviously inseparable from maternal health. The health of t:ie mother during pregnancy is unquestionably A major determinant of child health. But as we looked beyond pof I- physiological factors in child health, we found that our concern

well as mothers, Tast include fatH:rs as

in relation to their 7L,,. in the decisi:n to conceive a child, to their continuing in providing nurturance, support protection, and guid.-- , to their children as they grow. Not on_ is the family the prisAry unit for the delivery of health services to infants and :iiildren, but the family environment is proddbly the greatest influ,nce on a child's health. We wish :o be clear that our use r the term "macernf:, and chil : health," wh,n 4e describe and analyze both needs and inte7ventions, is in no way inconsistent wish our conviction t At fathers as wel:. as _ranchers are central to raising healthy chiLiren.

V:e are grateful for the opportunity you hive given us to eld;age in this work, and thank you for the help and support we have received from you and your associates in the course of ouc deliberations. W- trust that the value of our efforts will prove to have justified tree investment that the American public has made in the creation of this report.

I am sure you share with us the conviction that public policy, no matter how well conceited and carried out, can contribute only modestly to the vigor, gr.:se, and joy we wish to see in our children's lives. But as our repoft makes clear, public policy and programs can mean the crucial difference, especially in the lives of the most vulnerable of our children.

We hope most profoundly that this report will contribute to shaping public policy in ways that will help all American families and communities to protect and promote the health of all of our nation's children.

Respectfully and sincerely years, Eaktio. as saw.

.isbeth Bamberger Schorr

Chairperson

V
MFIV 11 3F THE SELE -7 PANEL

IR 17:1 IDNIOTION OF C17:. LD HEAL

L . larnh 2hairperson

,r. J E ice Chairperson

fc:- Crippled Children

iowa

Ann_

r'rofe:.-,

UCL., . Direc..27, lir_ ese.r-,_± Center

Los

ifitche 1. in:1

Dear. _m7 'ersity School of Social Work Nev 11.

:rank.Hi.1-- -: 7).

Obs:-.- -.ecologist

Nev rh, -.:K

Roger dm a

Vice -.ministration and Academic Affairs,

Sloan Kft=:,.nc2. ---:orial Institute

New Yor..i;, .,;ew : At.Yr

Profe 7 of Psych. .)gy and Preventive Medicine

Vanci:- It 1.Thiver- . Nash-

-7.ieorg.t :stilCOtt. LD.jAs it Surgec.- General and Administrator

He 3ervices

Pub Health Service. DHHS

loward Newman, J.D.

Adrn7nistrator, Health Care Financing Administration, DHHS

'Mr. '4ewman served from June 1980 to December 1980; he replacz. eo: rd D. Schaeffer who served from March 1979 to June 198'_
Katherin B. .D.

Prole :. -or of Nursini.-....).-hool of Nursing

:-sity of North -7ina

`'hap_ Hill, N prth f..1 r J Palmer. Ph.D.

As.istant Secretary : .ianning and Evaluation. L E-1HS

( D-. THaimer serveL. ii.im November 1979 to . iecember 19FO; he Benjamin ti Heineman, Jr. who served 70M March 1979 to

-er 1979.)

Cosa

...:-.. Secretary Juan Development

.riles served :- :ebruary 1980 to Dc

:::na Cardenas -z, Ed.D., Commis:

Cn: _ .en, Youth, ... Office

DHHS, wh '.-om March 19T

JuI . Richmond,

.:1:ant Secretary

Service, DHF

r. _Shirley, M.D.

Director, Jacks..

Mississippi

DHHS

nber 1980: he replaced

ier, Administration for

iuman Development

February 1980.)

. and Surgeon 3endral of the Public

Comprehensive Health Center,

me C. Sinkford, D.D.S., 1.E.

:an. School of Dentistry

,--ard University College entistry

ngton, D.C.

_ Tarjan, M.D.

:sor of Psychiatry

ector, Division of Me

aropsychiatric Institu

l LA School of Medici:

Angeles, California

-iotte Wilen

unding Chairperson. on Maternal and Infant Health,

StLte of Georgia

::tardation Program and Child Psychiatry

Ex Offici .ing members

tThe Panel members who are representatives of the Department of Health and Human Services wish to

commend the Panel as a whole for its thorough information gathering and careful analysis of child health

problems. They believe the Panels report is an extremely us::ful document. Nov:ever. the specific

programmatic and budget recommendations contained in the report have no'. yet been formally

c-nsidered by the Department or by the Executive Office of the President. Thus, participation by

Department representatives in the Panels activities canno: be construed as an Administration

endorsement of the recommendations.
STAFF REPRESENTATIVES FROM THE

DEPARTMENT OF

HEALTH AND HUMAN SERVICES

For the Assistant Secretary for Health and Surgeon General:

Susanne Stoliber

Deputy Assis=it Secretary

Office of Plarir..±ng and Evaluation

Juel Janis, Ph.D.

Special Assistant to the Assistant Secretary' for Health and Sur_ General

Samuel Kessell. M.D.

Special Assistant to the Assistant Secretary for Health and Su-.7ec-i General

Patricia Mullen, Dr. P. H.

Special Assistant to the Director, Office of Health Informati( an I Health Promotion

For the Assistant Secretary for Planning and Evaluation:

Bonnie Lefkowitz

Director, Division of Health Services and Resources

For the Administrator. Health Care Financing Administration:

Mary Tierney, M.D.

Director, Office of Child Health

For the Assistant Secretary for Human Development Services:

Linda Randolph, M.D.

Director, Health Services Branch, Administration for Children, Youth. and Families

Margaret A. Siegel

Special Assistant to the Assistant Secretary for Human Development Services
For thJ i.ant Surgeon General and Administrator, Health Services ,_ration:

Vince L. Fi ::ins, M.D.

:reau Director, Office for Maternal and Child Health,

Burea_ --ununity Health Services
SELEC T PANEL FOR THE PROMOTION OF

CHILD HEALTH

Professional Staff

John A. Butler, Staff Director

Sarah S. Brown, Associate Staff Director

Harriette B. Fox, Senior Program Analyst and Project Director, Volume II

Mary Grace Kovar, Senior Statistician and Project Director, Volume III

Martha Angle, Senior Editor, Volume I

K. C. Cole, Writing Consultant

Elizabeth des Cognets, Research Assistant

Barbara G. Furst, Editor, Volume IV

Jeanne G. Holzgrefe, Consulting Policy Analyst

Ruth J. Katz, Associate Program Analyst and Staff Attorney

Lorraine V. Klerman, Senior Research Associate

Jessica K. Laufer, Research Associate

Wendy Lazarus, Consulting Policy Analyst

Amanda F. MacKenzie, Public Liaison

Denise J. Meny, Demographer

Ellen Opper-Weiner, Coordinator, Public Hearings

Charlotte L. Tsoucalas, Law Clerk

Vicki Kalmar Weisfeld, Editor, Volumes II and III

Support Staff

Dorothy K. Cavanaugh, Senior Staff Assistant and Office Manager

Isabelle E. Duke, Administrative Assistant to the Staff Director

David James Dyer, Secretary

Constance Johnston, Administrative Assistant to the Panel Chairperson

Wendy Klaich, Secretarial Assistant

Michelle Miles, Secretary

Gail Milner, Administrative Secretary

Catherine Waller, Staff Assistant

xi
ACKNOWLEDGMENTS

The Panel wishes to express profound appreciation to its highly competent, hard working, and dedicated staff. We are particularly

indebted to John Butler and Sarah Brown for their splendid leadership

throughout our 18 months of work. We are also deeply grateful to the

members of the Department of Health and Human Services who assisted us, and to the contributors listed in the back of this volume. An

extraordinary number of individuals permitted us to disrupt their lives,

gave unstintingly of their time and wisdom, tolerated our deadlines, and

responded to our requests for help with unwavering understanding,

accurate information, and fresh insights. This can only be explained by

their deep commitment to the better health of the Nation's children.
SUMMARY

It is a biological fact that human infants and children depend upon

others to an extent not found in any other species. In tacit recognition of

this fact, all human societies, ancient and modern, have developed

elaborate systems of shared family and community responsibility for the

young. The makeup of such systems and the precise division of duties

v. them have varied from one culture to another and from one

ge, to the next. But the central theme of shared responsibility for

the yuun3 endures.

In the United States today, our system of shared responsibility has

contributed :nu& to ensuring the healthy growth of our children. But

despite great achievements, we are still falling short of doing what we

believe most Americans want to see done to promote the health of all our

children. In recognition of this fact, the Congress created a Select Panel

for the Promotion of Child Health to assess the status of maternal and

child health and to develop, for the first time, "a comprehensive pan to

promote the health of children and pregnant women in the United States."

The 17 private citizens and public officials who undertook this task

carefully scrutinized emsting maternal and child health data, knowledge,

and experience. We found widespread consensus about the interventions

likely to be effective, about the programs that work well and the obstacles

that keep them from working better, about ways to get the most out of the

money we are already spending, and about improvements that could be

achieved for relatively little more. We have also found that a large

proportion of the most burdensome child health problems can be

prevented or ameliorated at reasonable and predictable costs through the

application of knowledge already E hand The Panel was struck by the

contrast between how much we know about promoting the health of

pregnant women and children and how little is actually reaching some of

the most vulnerable among them. Similarly, we were impressed by the

number of highly successful efforts currently underway throughout the

country, but discouraged that they have not been systematically built

upon and expanded.

Even though we discovered much agreement on what needs to be done,

we found the task of developing specific proposals to improve maternal

and child health ever; more formidable than we originally anticipated. It

soon became evident that our very mandate was bucking widespread

feelings of alienation from Government, and a rising tide of cynicism and

hostility toward all social programs,

We believe that it is possible to take account of these currents in our

political climate without becoming immobilized by them. We recognized
early in our work that we must be cost-conscious as well as compassionate; incremental but with a clear vision of the long-term goals toward

which we aim. We have tried, as Congress asked of us, to be comprehensive, but without being unrealistic. We have made some sweeping but

practical proposals. They reflect the broad consensus in the land that even

the best public programs and policies can be made to function better when

they are more rationally and coherently related to one another.

Perhaps most important in terms of providing a basis for action over the

next decade, our proposals are justified by both a human concern for the

young and the self-interest of adults. Our recommendations to promote

maternal and child health are based on our deep beliefshared, we are

convinced, by most Americansthat children matter for themselves, that

childhood has its own intrinsic value, and that society has an obligation to

enhance the lives of children today, quite apart from whether we can

prove later benefits in adulthood.

We do not rest our case solely upon such convictions, however. What

we offer is also a prospectus for a sound investment in America's future, in

economic as well as social terms. Healthy children represent a major

economic asset. As today's children grow to adulthood, they will have to

perform increasingly complex tasks, in an age of constant technological

change, in order to protect our natural environment, maintain our

standard of living, keep our economy competitive with other nations,

preserve our defense capabilities, and maintain our humanitarian values.

We will tomorrow be dependent upon the very children who today are

dependent upon us. Each and every one of themmale and female, rich

and poor, black, ;gown, and whiteis both a precious individual and a

valuable national resource. Improving the health of today's children not

only enhances the quality of their lives immediately, it also expands their

potential for significant contributions to the Nation as adults.

We call upon all Americanspublic officials and private citizens,

parents and professionals, leaders at the local, State, and Federal levelto

join in concerted efforts to make certain that policies and programs in. the

1980's, in both the public and private sectors, reflect a commitment that

does justice to the needs of all of the Nation's children.

CHAPTER SYNOPSIS

Section IIntroduction

Chapter 1: Major Concerns

In the course of our work, five overriding concerns emerged. It is to

these concerns that we have addressed our analysis and recommendations:

(I) Many forms of disease prevention and health promotion are

demonstrably effective, especially for children and pregnant

women, but still are neither widely available nor adequately used

even when available.

2
(2) The health status of American children has improved dramatically over the past two decades, but not all groups have shared

equally in the progress. Sharp disparities persist in both health

status and the use of health services' according to family income,

ethnic background, parental education, and geographic location.

(3) The profile of child health needs has changed significantly over

the course of this century, partly as a result of success in

r mbating infectious disease, partly because new problems have

. aerged. But the organizational, administrative, financial, and

professional training aspects of our health care system today

have not been adapted to cope with current health problems,

which have intertwined psychological, environmental, social,

and behavioral components.

(4) While the family is and will remain the primary source of health

care for children, the current health care system insufficiently

recognizes or supports this role. Nor has the system acknowledged or adequately responded to the health implications of the

changing composition and circumstances of the American

family.

(5) The Nation's increased investment in maternal and child health

over the past two decades has spawned many new programs, but

they are not working effectively in relation to one another.

Public programs have made a significant contribution to improving the health of the Nation's mothers and children, but there

remain gaps in and between services; fragmentation and duplication in both programs and services; and conflicts among various

levels of government and among a variety of programs.

Section IIHealth Protection and Promotion

Many of the strongest influences on child health lie beyond the reach of

personal health services. These include the social environment, the

physical environment, nutrition, and health-related behavior.

Factors in the social environment such as family income, parental

education, opportunities for productive work, minority status, child care

arrangements, and the availability of community supports for adolescents

and parents of young children all exert a powerful influence on health. We

recognize the significance of these influences, but offer no extensive

recommendations in this area because it lies beyond the scope of our

mandate.

Chapter 2: Reducing Environmental Risks

Hazards in our physical environment can profoundly affect the health

of our children both before and after they are born. Our review of the

evidence on environmental hazards to mothers and children suggests there

are four risks which deserve special attention in the coming decade:

accidents of all kinds, with emphasis on motor vehicle accidents and those

in the home; chemical and radiation risks, including those posed by toxic

3
wastes, pesticides, lead and other pollutants; hazards from drugs and

foods, with particular focus on substances presenting special risks during

pregnancy; and problems caused by inadequate or unhealthful water

supplies, with attention to the need or wider fluoridation, potable water

in all homes, and adequate sanitation. These four types of risk include old

problems which could be prevented through the application of knowledge

already in hand, and new or newly discovered problems, which often are

complex in causation and less easil. understood or addressed.

Accidents, especially motor vehicle accidents, are the leading cause of

death and disability among children and adolescents. The United States is

second only to Canada among ten Western industrialized nations in its

rate of accidental deaths among children. The Panel believes this state of

affairs is unacceptable, and can be changed in a Nation as resourceful as

ours. A major new national accident prevention strategy should be

initiated, with strong participation by private industry, citizen groups, the media, and Government. This strategy should take advantage of both

private initiatives and public policy instruments, including technical

innovations, regulatory actions, and new approaches to education of

children and parents.

The evidence suggests that many kinds of injuries and health problems can be more economically and effectively reduced by changing the

environments in which people live, work and play, than by trying to

change behavior directly. Thus, for example, safer automobile construction and better passive restraint systems in automobiles may be more

effective than increased expenditure on driver education.

Among the most worrisome, pervasive, and complex environmental

health hazards are the numerous chemicals and sources of radiation to

which Americans are exposed in the home, at work, and in the

neighborhood. Toxic chemicals and radiation pose. special risks for

pregnant women and for children becauSe of the unique susceptibilities

early in the life cycle and because effects may be cumulative over the

lifespan. The Panel believes the Nation should clean up chemical wastes,

establish safe exposure levels for insecticides and pesticides, monitor the

use of X-rays, and take other necessary actions to protect the health of

current and future generation,.

One traditional public health objective which requires no new technology or knowledge is the elimination of obvious contaminants and sources

of infectious disease from water systems. Most Americans now benefit

from safe and healthy water, but three problems remain: many community water supplies are still not fluoridated, some families still lack indoor

plumbing, and certain potentially dangerous chemicals are still found in

drinking water.

The Panel believes that effective strategies to reduce environmental

risks for children and pregnant women must involve all Americans, and

not just the Government. Strategies for health protection should not be

automatically equated with regulatory action. But if Federal policy is to

continue to play an important role in protecting the health of children and

pregnant women, various Federal agencies will need to strengthen

considerably their coordination with one another over the coming decade.

4
Chapter 3: Health ant Behavior

Health-relewnt beh.., or is an integral part of lifestyle, which starts

forming in infancy. It i nfluenced by a wide variety of factors including

the examples set and in, truction given by parents, siblings, peers, schools, religious and commiL:nty groups, and the media. Socializationthe

combined effect of all !iese factorsis far more powerful than any single attempt to teach new h,,.,iaviors. but we now know a good deal about how

education in the fan, .y, schools. the media, the workplace, and the

community can exert a significant positive influence on health habits.

A mother's influence on the health of her child begins even before birth, when a number of maternal habits such as smoking, drinking, and drug

use can affect the outcome of pregnancy. The Panel believes that prenatal counseling and anticipatory guidance for parents, including preparation

for childbirth and education for parenting, should be more widely

available from health care providers, private voluntary organizations, and

community agencies. Similarly, guidance and support in the period

immediately after birth and in the first year of life can help a family cope with issues of infant feeding, how to manage a difficult baby, how to

recognize illness, and how to provide a safe and stimulating environment for an infant. The perinatal period also is an opportune time to !ink women and their families with other services and supports to ensure

continuity in the availability of primary care.

The rapid increase in numbers of preschoolers attending early education and day care programs otters a new opportunity for health-related

education. Eating habits, dental health practices, and other health

behaviors have their roots in early childhood, and the Panel urges that preschools and programs such as Head Start be used as sites for health

education and parent counseling as well as early identification of health

problems.

Television exerts a powerful influence on formation of behavior from a

very early age. The Nation must improve the quality of programming

directed at children, particularly with regard to both implicit and explicit health messages; we must also preserve our capacity for regulatory action aimed at mitigating any negative health consequences of television programming and advertising targeted toward children. In addition, parents, policymakers, and community groups should encourage alternatives to excessive television viewing among children. Inordinate time spent watching television diminishes the opportunity for more active ways of

learning about life.

Many school health education programs at present are neither suffi- ciently comprehensive nor sufficiently attuned to the influence of peer culture and other important determinants of youthful behavior to be truly

effective in promoting good health habits: The content of school health

education should remain a matter for local determination involving active parental participation, but should include sound information and guid- ance on such topics as eating habits and nutrition, exercise, smoking, alcohol and drug use, driving safety, human sexuality, family develop- ment, coping and stress management, and environmental conditions

5
affecting health. Physical educa2don programs in particular are an area of

vast unrealized potential. These should place new emphasis on lifetime

fitness and health maintezance skills as well as competitive team sports.

Because so many forms o behavior with lifetime health consequences

are formed or first tried In idolescence, health education activities are

especially important for youngsters 10 to 18 years old. Although most

adolescents are physically healthy, problems ranging from accidents to

substance abuse and um. _toted pregnancy can result from immature

judgment combined with _:certain self-esteem and strong peer pressure.

Adolescents need more in ,rmation about the effects of their lifestyle on

their present and future he,ith, but such information must be presented in

ways which are likely to he taken seriously by them. This suggests a

special responsibility for those most likely to be heeded by teenagers,

including 'nfluential teachers and community leaders, sports figures, and

television and radio celebrities.

Chapter 4: Improving Nutrition

The critical role that nutrition plays in health has not been adequately

recognized by the health community generally, including those whose

principal focus is maternal and child health. We share the developing

consensus that nutrition is a major, not marginal, component of efforts to

promote health and prevent disease, especially during pregnancy, infancy,

childhrcJ,, and adolescence when the human organism is growing and

developin,g.

While there are still some who lack adequate food, starvation and gross

nutritional deficiency diseases are no longer the major problems they once

were. Today's nutrition problems are more likely to involve dietary --

exces.les and imbalances which may in turn be implicated in the

development of leading chronic degenerative diseases. Adequate nutrition

is especially important for some mothers and children who, by virtue of

such factors as socioeconomic and minority status, age or cultural

background are at special risk of nutrition-related problems.

The Panel identified four ways to improve the nutritional status of

mothers and children:

(1) There must be a new and vigorous commitment in the health

system, schools, the media, private industry, and Government to

inform and educate families more adequately about healthpromoting and risk-reducing diets. The Panel urges the Federal

Government to take a major leadership role in developing and

disseminating norms for appropriate nutrition. Nutrition-related

guidance must take cognizance of our new "nutrition environment," which is characterized by new patterns of eating, a

rapidly changing food supply, phenomenal growth in convenience and processed foods, and fast food restaurants.

(2) Nutrition services must be better integrated into health care.

Health care providers should specifically address their patients'

nutrition-related needs as part of the full range of health services

offered, and should link their practices to nutrition services in

their communities.

6
(3) Existing public food programs also must be strengthened and

expanded. Over the long run, the Supplemental Food Program

for Women, Infants and Children (WIC) should be enlarged to

serve all who are eligible by income and nutritional risk; State

and local health care systems which provide the base for the

WIC program should be expanded accordingly.

(4) Research is needed to develop a better understanding of

children's diets, nutrition, and health status; to identify individual and family nutrition-related behaviors that increase children's

risks of disease and to develop ways to help families change such

behaviors; and to develop greater understanding of the effects of

early feeding patterns and nutritional status on long-term

development and adult health status.

Section IIIThe Content, Organization, 4nd

Financing of Health Services

The Panel concluded early in its work that any proposals we might make for changes in the organization and financing of health services

should grow out of an assessment of what services children and pregnant women actually need, in addition to an analysis of current patterns of service use and the strengths and shortcomings of existing programs. We

focused our attention most heavily on primary care, in the belief that it is

the area with the most urgent unsolved problems. Similarly, we directed

much of our analysis to the way in which health services for mothers and

children are organized and financed, believing that such health system

components exert a major influence on health status.

Chapter 5: Needed Services

The task of defining "needed services" was a fundamental first step in

the Panel's work and served as the basis for many of our subsequent

recommendations, particularly those regarding the organization and

financing of health services. Because health problems in this group range

from the biomedical to the psychosocial, needed services include services

such as counseling, anticipatory guidance, and various information and

education activities oriented primarily to psychosocial issues, in addition

to traditional medical care.

We focus mainly on services that are preventive in nature and are

typically delivered through primary care systems. This orientation stems both from the Panel's mandate and from our belief that many of the

strategies most likely to decrease overall mortality and morbidity in mothers and children lie in the domain of preventive services and primary

care. This emphasis is accompanied by our conviction that the expansion

and improvement of secondary and tertiary services to mothers and

children who need such care is also critical and requires more adequate

resources and improved coordination between primary care and more

specialized services.

7
Chapter 5 presents lists of health and health-related services that should

be fully available and accessible to women in the reproductive age span,

including pregnant women; infants in the first year of life; preschool and

school-aged children; and adolescents.

The process of defining needed services led us to three major findings.

First and most important is the conclusion that for three broad classes of

services, there is such a clear consensus regarding their effectiveness and

their importance to good health that it should no longer be considered

acceptable that an individual be denied access to them for any reason:

Prenatal, delivery, and postnatal care

Comprehensive health care for children from birth through age 5

Family planning services

A Q.,cond category of services which merit special attention includes

mental health and related psychosocial services, dental services, genetic

services, and services that promote access to care. Although each has

unique attributes, they have in common not only their importance to

health but also the fact that they are not now adequately available,

particularly to some of the groups most in need of them, and that they

have not been accorded sufficient prominence in current views of the

essential components of maternal and child health care services. By

singling them out for specific discussion, the Panel hopes to strengthen the

national consensus regarding their value in health promotion.

Third, a new mechanism is needed to serve a variety of functions aimed

at improving the content, quality, and availability of health services for

mothers and children. One reason many services we have identified as

needed are unavailable or underutilized is that they are not covered by

public and private third-party payment plans, in part because of the

nature of the services themselves. They tend to be difficult to define

precisely, andin greater measure than is true for medical servicestheir

effectiveness appears closely related to the circumstances under which

they are provided, by whom, and in relation to what other services. To

help provide information on such issues, we recommend that a Board on

Health Services Standards be created, or existing institutions strengthened

and consolidated, to perform the following functions:

Review and define the health services that should be available to

mothers and children in light of new knowledge and changing

health problems.

Provide guidance to third-party payers and purchasers of health

insurance regarding the effectiveness and appropriate use of a

given service or sets of services, and the circumstances under

which such services should be provided and financed.

Provide information to third-party payers regarding the likely

effects of their payment policies and practices on the availability

of needed services, professional personnel, facilities, and other

health resources.

So that work along these lines can proceed promptly, we recommend

that the Secretary of Health and Human Services convene an ad hoc

group to propose the precise nature, composition, and authority of the

8
Board within the broad guidelines we propose, and that the Congress act rapidly to establish the Board or a similar mechanism to perform these

important functions.

Chapter 6: Improving the Organization of Health Services

Primary care for children and pregnant women is currently provided under a wide variety of arrangements, which range from privat physicians' offices to the public schools, from health department hospital clinics to community health centers and health maintenar.

organizations (H MO's).

American communities vary so widely in their needs and resources, a: prize so highly the diversity of their own'ways of solving problems, that is neither feasible nor wise .to attempt to move the Nation toward

standard way of delivering health services to mothers and childrc However, we have identified specific organizational attributes whiL should be incorporated into all provider arrangements. The effective organization and structuring of services is especially important for families with handicapped, chronically ill, or severely ill children; for pregnant women who for social or medical reasons are at high risk; and for lowincome families, who have greater needs for health and related services and fewer resources to negotiate their way around a complicated maze of fragmented health services. Since these categories of families include perhaps one-fifth of all children and pregnant women at any one time, and one fourth to one-third over a period of years, the need for more highly organized primary care is not circumscribed, but spread widely through- out the population.

The attributes that we have identified as important components of effective primary care provider arrangements are: Comprehensive services

Accessibility

Capacity for outreach

Coordination of services

Continuity of care

Appropriate personnel arrangements Accountability

Consumer participation

Partnership with parents We have analyzed a number of existing provider arrangements with these attributes in mind, and have made proposals for strengthening them. We believe that, over the long term, primary care physicians should be

encouraged to join in practice with other physicians and with other health

professionals. Dentists, too, should be encouraged to join in practice with other dental professionals. Simultaneously, new efforts must be made to develop better :inks between providers in office-based practice and other sources of care. services, and support in the community. Hospitals that provide a substantial amount of outpatient care to children and pregnant women must make fundamental changes in their

9
organizational arrangements by establishing primary care centers, hospital-based group practice, and better linkage with other sources of care in

the community. None of this can be accomplished without changes in the

financing of hospital outpatient services, and we recommend a number of

specific changes toward that end.

Publicly financed comprehensive care settings (including community

health centers, migrant health centers, children and youth proje. 's,

maternity and infant care projects, some health department programs. _nd

rural primary care centers) have been highly effective in proviuing

previously unreached populations with needed hev...h services, with

subs.iguent decreases in hospitalization rates, infant mortality rates, and

the .7,cidence of preventable diseases in the areas ser.:d. They remain a

moczi for the delivery of high-quality care in the Nation's areas of

pro:der scarcity and high health needs.

W believe these programs, along with the deployment of National

Health Service Corps personnel, are the best instruments for increasing

access to and availability of primary care services for children and

pregnant women in underserved areas, and that the Congress should

increase its grant support to allow existing comprehensive care centers to

serve more clients and to permit their expansion to additional sites.

Because HMO's provide cost and quality controls, the opportunity for

collaboration among a variety of health workers, and a system of

financing which encourages the provision of primary care and preventive

services, the Panel urges that all HMO's expand their ability to provide

needed services to children and pregnant women, and that Federal

authorities take the steps necessary to make it more attractive for HMO's

to enroll low-income mothers and children.

Support for primary care units organized and sponsored by qualified

local and State health departments will be even more important during the

next decade than in the past. In many areas, no other provider is as likely

to offer care at moderate expense to the inner city or rural poor and the

medically indigent. We therefore recommend that Federal, State; and

local authorities support health department efforts to offer comprehensive

primary care, rather than individual components of preventive care.

School-based health services should be considered a desirable way of

delivering primary health services to school-aged children, and possibly to

preschool children, in those communities where it is possible to utilize

schools as the site for the provision of health services rendered under the

auspices of an appropriate health agency, and where parents support and

actively collaborate in fashioning and maintaining such arrangements.

Nonetheless, there are many schoui systems where it will not seem wise to

locate a comprehensive primary care program in the schools. In such

instances, professionally qualified nurses should provide health education,

counseling and preventive services, work with parents to link children with

other health services, and provide professional nursing supervision for

children with chronic illness or handicapping conditions. Similarly, we

believe a more extensive commitment of resources aimed at improving

health services for children in day care, Head Start, and other preschool

programs is essential.

10
Chapter 7: Delivery Problems of Special Concern

In its review of arrangements for the delivery of needed health services

to infants, children, adolescents, and pregnant women, the Panel identified a number of special challenges or opportunities in organizing health

services that cut across individual provider arrangements. We believe

these should be specifically addressed in the fbr:nulation of public policy.

Home Visiting

Renewed interest in home s. '.siting services has developed from a growing recognition that many services are best provided outside of large

institutions, that traditional sources ofsupport for many pregnant women

and new parents are often no longer available, and that efforts to link

persons with the services they require are often essential to obtaining good health care. Federal, State, and local authorities should substantially

increase their support for home visiting programs. Such increased support should be of sufficient magnitude to: permit a substantial number of States and communities to use home visits by public health nurses or other qualified personnel as one means of ensuring access to the minimum basic health services for children and pregnant women discussed in chapter 5; enable various health care providers to establish or reestablish home

visiting programs as a routine ,component of maternal and child health

care; and allow for the evaluation of a wide range of programs.

Primary Mental Health Care

Many health problems which . Jrne to the attention of primary care practitioners are either emotional in origin or have important psychosocial

components. Furthermore, a significant portion of what might be termed

"primary mental health care" is in reality provided in general health care

settings and in schools, day care centers, juvenile detention facilities, and other sites by personnel not specifically trained as mental health

professionals. These facts must be better recognized in the organization

and financing of services, in the training of health professionals, and in

arrangements to provide expert mental health support and consultation to

parents, general health care providers, teachers, day care workers, social workers, correctional officers, and others who deal with children and their families daily.

The time is ripe for new and systematic efforts to organize and finance primary careespecially for children and pregnant womenin ways which will encourage adequate attention to psychological, social, and

behavioral components of care and which encourage referral, consultation, and ease of communication between mental health professionals and primary care providers, and agencies, institutions, and professionals who deal with children, pregnant women, and parents in trouble.

Categorical Services

In the main, primary health services for mothers and children are

provided most effectively in settings that offer a comprehensive array of

11
needed services. But there is persuasive evidence that some services are

well provided in settings that are not organized to provide comprehensive

care. For example, the Panel recommends that categorical funding for

family planning services be expanded to ensure that these services

continue to be made available in a variety of settings; and that all persons

who wish to make use of family planning services will have access to them.

The potential effectiveness of providing preventive dental services to

school-age children through categorical programs has been grossly

neglected. Certain basic preventive dental services are so critical to

improving the dental health of the Nation that they must be available to

all children and in various sites such as public schools, which simplify

access and provide substantial economies of scale.

Mass Screening

Screening is useful (a) when performed in the context of individual

assessments and continuing care, (b) as a means of detecting a limited

number of conditions characterized by simplicity of detection and

followup, (c) as a way of linking children to an ongoing source of care,

and (d) as a check on the adequacy of care that children are receiving.

Developmental assessment is a key component of the health assessment of

every child, but developmental assessment of young children is not

properly performed as part of a mass screening program, and should be carried out only in the context of a more comprehensive health or .

educational assessment.

Hospital Care

The operating and staffing policies, environment and design of space, and philosophy of care of all hospitals offering pediatric and obstetrical

care should reflect the developmental and psychosocial needs of children

and families in health care settings. All hospitals with emergency rooms

that treat children should ensure the availability of special pediatric

equipment and of medical and nursing staff knowledgeable in the care of

critically ill or injured children.

Regionalization

The Panel urges increased support for the regionalization of selected

health services for children, newborns, and pregnant women, including

further development of regionalized perinatal care networks; genetic

services; networks to improve rare or serious illness and accidents;

backup and referral services for diagnosis and treatment of children with

chronic illness, handicaps, or complicated psychosocial problems; and

enlarged public and private support of children's hospitals in their role as

regional resource centers and providers of specialized care.

Chapter 8: Organizing Services for Special Populations

Four populations of children present special challenges to the effective

organization of services: adolescents, chronically impaired children,

12
children in foster care or other out-of-home placements, and children with

serious access problems as a result of linguistic, cultural, or geographic

separation from the mainstream of society.

The health care needs of adolescents require increased attention in

existing health services systems, and efforts must be made to develop and

refine innovative models for organizing services to meet special health

needs arising during this important period in the life cycle. Outreach

systems should be targeted to the settings where adolescents spend most of

their time; counseling should be a major component of adolescent health

care; sensitivity to issues of privacy and confidentiality must be reflected

in the design of services for this population; and financial barriers to care

must be significantly reduced or eliminated.

Certain basic principles should govern the provision of all health

services for chronically impaired childrena group including the chronically ill, physically handicapped, mentally retarded, emotionally disturbed

and multiply handicapped. Routine care should be provided in the home

or as near to normal settings as possible; hospitals should design systems

that maximize use of nearby homelike settings, including hospice care

where necessary; primary care needs including mental health, dental care

and support services for children and families should not be overlooked;

and the hidden costs of care for chronically impaired children should be

taken into account in private and public financing of care. Clearer

guidelines and specifications are needed in a number of public programs directed at these children. The efforts of maternal and child health

authorities in this regard should complement school-based efforts under

P.L. 94-142, the Education for All Handicapped Children Act.

Juveniles in confinement and in foster care are often overlooked by the health care system. Detention and correctional facilities have an obligation to meet the health and mental health needs of juvenile offenders, and

offenders should not be placed in facilities which lack services to meet

their needs. The Panel also recommends that required care plans for children in foster care include thorough periodic assessments, and

statements of the children's health needs, the health services being

provided, and the agencies or individuals responsible for providing such

services.

Migrants and farm workers often have inadequate access to publicly

financed health and social service programs, which typically depend on

stable residency as a criterion for eligibility. The Migrant Student Record

Transfer System, a computerized system enabling education authorities to

track migrant children from school to school, should be used to link

migrant health service programs so that selected health information can

move with the child as families change location. In addition, State health

plans should contain explicit provisions for meeting migrant health care

needs.

Native American children also have special health care needs. Increased

numbers of Native Americans should be helped to enter the health

professions; more team care should be available; alcohol abuse and other

behavioral problems should be effectively addressed; water and sanitation

services should be expanded; and primary care for urban Indians should

be improved.

13
While refugees, "entrants," and illegal immigrants all share common

problems in obtaining health services, they are treated quite differently by

law and public policy. For refugee children the main problem is the

discontinuity which is built in by the 3-year eligibility limit for benefits

under the Refugee Act of 1980. No distinction should be made between

refugees and "entrants" in determining eligibility for health care for

children and pregnant women. In areas where illegal immigrants represent

a significant component of medical indigents, means should be sought by

the Congress, the Department of Health and Human Services (DHHS)

and the States to provide fiscal relief to hospitals and primary care

providers requiring such assistance.

Chapter 9: Financing Health Services

The way in which health services are financed is the single most

important determinant of how the health care system operates, what

services are available, which professionals provide those services, and who

will receive them. Current public and private third-party payment systems

provide incentives that result in an allocation of physician time,

distribution of physicians by speciality s, location, and a manner of

providing health services that collectively are unresponsive to a significant

part of patient needs, especially those of children and pregnant women,

and that unnecessarily drive up health care costs. Further, current

financing arrangements leave millions of Americans with no public or

private health insurance protection whatsoever, and many millions more

with grossly inadequate coverage.

Purchasers of health insurance, public and private third-party payers,

and health care providers should take steps to modify and create

alternatives to prevailing methods of reimbursing health professionals and

institutions, including:

Revision of payment schedules and methods to reflect the value of

counseling and other time-intensive aspects of primary care and to

decrease inappropriate incentives for performing technical procedures.

More widespread use of alternatives to fee-for-service payment

methods.

Methods of reimbursement that offer equal incentives for training

health professionals, in ambulatory care and inpatient settings.

Third-party payers and purchasers of health insurance need better

guidance on which services are in fact needed, who is qualified to provide

them and under what circumstances. The Board on Health Services

Standards recommended in chapter 5 is designed to provide such

guidance, and also to provide information regarding the likely effects of

third-party payment policies and practices on the availability of needed

services. professional personnel, facilities, and other components of the

health care system.

Private Health Insurance

The potential of private health insurance plans for advancing maternal

14
and child health remains to be fulfilled. Toward that end. the Panel

recommends that State insurance commissioners review private insurance

policies approved for marketing in their States and grant certification to

those that meet the health needs of children and pregnant women. In

determining which policies merit certification, the States should use

criteria advanced by the proposed Board on Health Services Standards.

Medicaid

The Medicaid program has removed economic barriers to needed care

for many poor families. However, the adequacy of the program varies

greatly among States, and in some instances, restrictive State policies

result in tremendous economic hardships and barriers to needed care for

millions of families. For example, in 19 States, women who are pregnant

for the first time do not qualify for prenatal benefits. Only about twothirds of all poor children are eligible for Medicaid; and an estimated 7

million children wno meet Federal criteria of poverty cannot receive any

Medicaid benefits at all. This is because many States do not allow children

of two-parent families to participate in Medicaid, because income

standards for eligibility are low in some States, and because many who are

eligible during part of the year lose eligibilty when family circumstances

change.

Many current problems with the program could be ameliorated without

changing its basic structure as a Federal-State program focused on the

poor. The most important improvements are incorporated in several

versions of the Child Health Assurance Program (CHAP) pending before

Congress; these improvements should be promptly enacted. Specifically,

the Panel recommends immediate action to establish a uniform national

income and resources standard and the extension of eligiblity to all

children and pregnant women who meet that test, regardless of family

status or other conditions; to require coverage of a uniform national

package of services; to include all qualified providers; and to provide

Federal incentives to the States to expand access to services and

encourage continuity of care.

National Health Financing Programs

Even if the improvements we recommend are made in private insurance

and Medicaid, some people will remain uncovered by any form of health

insurance, public or private, and many parents will still be forced to

choose between health care for their children and the purchase of other

necessities.

It is the Panel's conviction that the health care needs of children and

pregnant women will be best served over the long run by a national health

financing program that ensures universal entitlement to health care. If

such a plan cannot be put in place relatively soon, the Panel urges

enactment of national health insurance for pregnant women and children

to 18. If it proves necessary to phase in eligibility even for this population,

the Panel recommends starting with a program covering all pregnant

women and children through age 5.

Is
Grant Programs

The Panel supports the use of expanded grant programs to: Encourage the development of resources in geographic areas

where the personnel, facilities, or delivery mechanisms to provide

health care services are unavailable, and to finance demonstrations of new and better ways to deliver such services.

e Pay for services that are more appropriately financed through

grant programs than through third-party payments, and for those where more information is still needed regarding the most effective methods of payment.

Pay for comprehensive services for persons such as handicapped

children who have health care needs best met through special

systems or programs.

Pay for health services for those persons lacking other sources of

payment, such as migrant workers, poor individuals not eligible

for Medicaid. and illegal immigrants.

Section IVGovernmental Relationships

The Panel concluded that the interrelationship of local, State, and Federal Government in the area of maternal and child health needs

reordering and simplification. Suggested changes pertain not only to

agencies that provide or support services directly, but also to those that

perform broader functions such as planning, monitoring, and advocacy.

Chapter 10: Structuring the System

The major health and health care objectives the Panel has identified can

be attained without creating major new public programs. But it is essential to enhance the complementarity of existing programs, clarify responsibilities for those making policy and administering programs, and achieve

improved coordination and program management.

The Panel believes that the current disarray of programs and policies is sufficient to merit a major modification in the Nation's policies and

programs for improving the health of mothers and childrenequal in

significance to the creation of the Children's Bureau in 1912 or the passage of the Title- V legislation in 1935. The agenda this time must be to

simplify program oversight and management while ensuring the achievement of specific, socially agreed-upon objectives. We propose that various

steps be taken to establish more coherent State and Federal administrative

structures, to redefine the appropriate relationship between State and

Federal authorities responsible for relevant programs, and to improve

local service coordination.

Every State should work toward placing authority over all relevant

funding streams in an appropriate division of the State health unit, and a

strong unification of effort should be promoted around all aspects of care

for children and pregnant women, including handicapped children.

While it is difficult to increase both State autonomy r:1:?d Federal

accountability simultaneously in working toward national objectives,

16
several steps can be taken that will serve both purposes. These include

Federal accountability mechanisms that stress the Federal role in

establishing broad performance objectives and standards and the State

role in selecting methods for attainment of these; joint applications and

reporting forms for all Federal programs related to the health of children

and pregnant women; a new set of coordination criteria to be met by all

new or continuing legislation and program regulations; and interagency

agreements to identify areas of responsibility, define specific steps to be

taken, and assign realistic time frames for the attainment of goals.

Title V continues to be an essential element for providing health care

services and for increasing the coordination of all State and Federal

programs relevant to the health of children and pregnant women. We

recommend that Title V be revised and expanded, according to the

specifications detailed in volume II of the report, to provide the necessary

leadership and policy focus.

It is especially at the local level that the efforts of service providers must

be simplified and unified in order to provide effective services. At least

two types of local initiative have proven successful: the establishment of a

single point of service administration and budget control, and the

development of improved methods of case management and case

advocacy. Each locality should designate a lead agency or publicly

appointed body to assess whether the existing network of private and

public health care arrangements is sufficient to meet the health care needs

of local children and pregnant women, and to recommend changes as

needed.

We also urge Federal, State, and local authorities to take a number of

steps to better harness existing policy functions applying to all public

health programs. These functions include planning, quality assurance,

development of information systems, research and demonstrations,

technical assistance-consultation, and advocacy.

Chapter 11: Federal Administrative Arrangements

The new national commitment to protect and promote the health of

mothers and children which this report advocates can he best advanced at

the Federal level through the creation of a Maternal and Child Health

Administration (MCHA) within the Public Health Service, to he made up

of the existing Office of Maternal and Child Health, the Adolescent

Health and Pregnancy Prevention Program authorized by P.L. 95-626,

family planning services supported by Title X of the Public Health

Services Act, and possibly other programs at some future time.

Maternal and Child Health Administration functions should include (a)

operation of these programs; (b) authority to review and comment on

major policy issuances, including proposed budgets and legislation,

developed by other agencies within DHHS that conduct activities directly

related to maternal and child health with a view toward achieving better

coordination of programs; (c) assistance to the States on maternal and

child health-related topics to help ensure that all mothers and children

within their jurisdictions have access to needed services; (d) responsibility

for setting national standards by which to assess the adequacy of the

17
States' progress in ensuring the availability of the minimum set of basic

essential services; (e) coordinating the maternal and child health programs of DHHS with related programs in other departments, such as the WIC

program of the Department of Agriculture, and the Education for All

Handicapped Children activities of the Department of Education; and (f) research and advocacy. The primary value of the MCHA, in the Panel's

view, is that it would be an organizational entity of sufficient stature and

prestige to mobilize and coordinate programs and sources of funds in many separate agencies in the service of improved maternal and child

health.

The Panel decided against recommending that the EPSDT program be moved from the Health Care Financing Administration (HCFA) into the new MCHA. We concluded that its removal from the rest of Medicaid

would create delays and disruptions in providing services. More importantly, its relationship to other maternal and child health programs

represents a 'small part of a much larger issuethe relationship of all

Public Health Service (PHS) programs to all programs administered by HCFA. A number of steps should be taken to link the service orientation

of PHS with the financing and management capacity of HCFA. The

establishment of the proposed Board on Health Services Standards could

be expected to supplement HCFA's existing expertise in management and

cost-containment and thus enable it to perform a broader mission

including health promotion and disease prevention. We recommend that

the Secretary of DHHS give urgent consideration to other possible steps in

this direction, such as making both PHS and HCFA responsible to a new

Under Secretary for Health.

The Panel also proposes the creation of a National Commission on

Maternal and Child Health, appointed by the Secretary of DHHS to

report every 3 years on the health status and unmet service needs of

mothers and children; to recommend policy changes in Federal maternal

and child health programs, especially to improve their effectiveness and to

enhance coordination among programs; and to serve as an advocate,

particularly in Congress, for the health needs of mothers and children.

We also recommend joint oversight hearings by the appropriate

committees of House and Senate to increase the coordination of maternal

and child health programs that fall within the responsibilities of different

committees.

Section VManpower and Research

Many of the Panel's recommendations suggest new roles and relationships among the health professionals who provide care to children and

pregnant women, and underscore the importance of continued and

expanded research.

Chapter 12: Health Professionals

Many of the views and recommendations presented in this report contain major policy implications regarding the training and deployment of professionals in maternal and child health. These include:

The changing profile of primary care needed by mothers and

children, with its emphasis on health promotion and disease

18
prevention activities, requires new components in the training of

all primary care providers.

Meeting the health needs of pregnant women, children, and

adolescents will increasingly require a team approach to the

delivery of primary care.

The anticipated increase in the overall supply of primary health

care providers in the coming decade makes possible, but does not

by itself ensure, better access to health care for those most in need.

Improved distribution of services will depend, among other things,

on alterations in the deployment of National Health Service Corps

personnel and on creative use of providers with different levels of

training and expertise.

Training of maternal and child health personnel involved in

program administration and policymaking at the Federal, State, or

local level must be modified to equip such professionals with the

broad range of skills required for management roles in complex,

interrelated service systems and to bridge the worlds of maternal

and child health, obstetrics, and pediatrics.

Chapter 13: Research

The Panel emphasizes the importance of research directed toward

increasing understanding of the biomedical, behavioral, and environmental determinants of health and disease, and toward the improvement of

our health delivery system. A wide array of scientific disciplines, pursued

at both the fundamental and the applied levels, must be employed

biomedical, behavioral, and social research, the population-based health

sciences, health services research, and related disciplines.

The Panel vigorously supports the pluralism of research orientations

and agencies currently supported by the Federal Government, but

recognizes such diversity of effort requires broad-scale research planning

and coordination. We recommend that the Assistant Secretary for Health

undertake periodic and careful review of the activities of Federal agencies

supporting health research, and of the relationship of current research

priorities to the evolving needs of mothers and children, to minimize the

risk of significant gaps developing in the total research effort.

We call attention to several research domains of special importance:

epidemiology, prevention, social and behavioral aspects of health, health

policy, evaluation research, and research on environmental risks to health.

We also recommend strongly that support for fundamental research in the

health sciences be sustained and increased as opportunities emerge and

resources allow, and that special efforts be made to ensure that support for

new or neglected areas of research not be made at the expense of

fundamental research.

To support many of the research needs we identify and to improve the

content. organization, and financing of health services, a more adequate

pool of statistical and survey data is needed on a great variety of maternal

and child health issues. We .tress simultaneously that massive amounts of

data already in hand are inadequately analyzed and reported.

Because a well trained., steady supply of researchers is a cornerstone of

any national strategy to prevent disease an,d promote health, we view the

19
current trend toward erosion of training support with great concern. Also,

in order to further stimulate research on the health issues and interventions which are particularly important in primary care and to maternal

and child health, the Panel recommends that research training opportunities be increased in ambulatory primary care settings and other settings

oriented to health promotion and disease prevention.

PLAN FOR ACTION

The Panel views the spectacular improvements in child health achieved

by this nation in the past half century as providing a firm foundation on

which to build for the future. We have identified the areas in which major

problems persist and further improvements are urgently needed.

To clarify the interrelationship among the many recommendations we

make throughout the report, we propose three sets of goals.

(1) The first set of goals is directed at ensuring that all needed health

and health-related services are available and accessible to all

infants, children, adolescents, and pregnant women:

First, to ensure universal access to three sets of minimum basic

services: prenatal, delivery, and postnatal care; comprehensive

care for children through age 5; and family planning services.

Second, to bring about the more effective operation of

governmental activities aimed at improving maternal and

child health.

Third, to improve the organization of health services to reach

those population groups with special needs or at special risk,

including adolescents, chronically impaired children, children

in institutions and foster care, and children in the families of

migrant and farm workers, Native Americans, refugees, and

illegal immigrants.

Fourth, to ensure that a family's economic status shall not be a

bar to the receipt of needed health services or determine the

nature and source of such services, and that the use of such

services shall never reduce a family to penury.

Fifth, to ensure that every child from birth to age 18 and every

pregnant woman has access to a source of continuing primary

care.

Sixth, to ,nsure that every family, child, and pregnant woman

has access to all services identified as "needed," not merely

those basic minimal services which are part of our first goal.

This includes genetic, dental, and mental health services and

services to respond to health problems with major social and

behavioral components.

(2) The second set of goals we propose addresses the influences on

maternal and child health which lie beyond the reach of personal

health services:

First, to encourage all efforts aimed at reducing accidents and

risks in the physical environment, and to bring about greater

recognition of the particular vulnerability of children and

pregnant women to environmental risks.

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Second, to promote greater understanding and acceptance of

the critical role of nutrition by private industry, Government,

the media, the schools, and community groups as well as by

the health system.

Third, to enlist the schools, the media, industry, and voluntary

associations, as well as the health system, in far more vigorous

efforts to help individuals adopt and sustain behaviors that

enhance health and well being. . (3) The third set of goals we propose is directed at building the

knowledge base necessary to further enhance maternal and child

health:

First, to encourage both the public and private sector to

pursue a wide range of research spanning not only the

biomedical and behavioral sciences, but also the populationbased sciences and health service research.

m Second, to recognize that fundamental research remains the

cornerstone of many past and future advances in health.

Third, to ensure that an adequate portion of research support

is directed to the special health problems of mothers and

children.

It is clear that progress toward achieving these goals will require

integrated and coherent action. We recognize the difficulties involved in

achieving such action, especially if the necessary steps involve any

fundamental change. With an eye to constraints on both available public

funds and advocacy energies, we suggest that many changes can be made

incrementally without diminishing their effectiveness, as long as there is a

clear vision of long-term goals. We urge policymakers and advocates, in

adopting such an approach, not to lose sight of the relationships among

the parts.

Progress toward these goals will also require considerable attention to

detail. For this reason, we devote the second volume of our report to

spelling out the implications of our recommendations for immediate

action to improve five Federal programs with a major impact on child

health: Medicaid and EPSDT, the WIC Supplemental Food Program,

Title V (Maternal and Child Health and Crippled Children's Programs) of

the Social Security Act, the Education for All Handicapped Children Act

(P.L. 94-142), and Community Mental Health Centers and Service

Systems. In volume III the Panel also presents a compendium of

background data on various aspects of maternal and child health, and in

volume IV a series of relevant background papers. Both are intended to

provide additional information to assist policymakers and the public to

arrive at informed judgments in their efforts to improve child health.

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* U.S. GOVERNMENT PRINTING OFFICE : 1981 0 - 339-243 (EXECUTIVE SUMMARY)