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

agencies2

 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 pregnancy9

 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 paraprofessionals26 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. 104-

193) 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.

XX 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.

XXX

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 XX X XX
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 XX X XX

Increase overall state contributions to

WIC NSA.

X XX X XX

Increase the level of WIC funding from

other sources.

X XX X XX

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.
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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.
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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.
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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
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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
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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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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:
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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.
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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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• 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).
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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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• 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.
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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.
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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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