Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

APRIL 2000 

OEI-04-98-00090 

MATERNAL AND 

CHILD HEALTH TRAINING GRANTS 

THE LEND PROGRAM 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, and 

amended by Public Law 100-504, is to protect the integrity of the Department of Health and 

Human Services programs as well as the health and welfare of beneficiaries served by them. This 

statutory mission is carried out through a nationwide program of audits, investigations, 

inspections, sanctions, and fraud alerts. The Inspector General informs the Secretary of program 

and management problems and recommends legislative, regulatory, and operational approaches to 

correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 

Inspector General. It conducts short-term management and program evaluations (called 

inspections) that focus on issues of concern to the Department, the Congress, and the public. The 

inspection reports provide findings and recommendations on the efficiency, vulnerability, and 

effectiveness of departmental programs. 

OEI's Atlanta Regional Office prepared this report under the direction of Jesse J. Flowers, 

Regional Inspector General, and Christopher H. Koehler, Deputy Regional Inspector General. 

Principal OEI staff included: 

REGION HEADQUARTERS 

Janet Miller, Lead Analyst Alan Levine, Program Specialist 

Josiah Townsel, Team Leader Barbara Tedesco, Statistician 

Dwayne Grant, Program Analyst Brian Ritchie, Program Analyst 
TABLE OF CONTENTS 

PAGE

EXECUTIVE SUMMARY ............................................... 1

INTRODUCTION ..................................................... 3

FINDINGS

Success In Interdisciplinary Treatment of Children ............................ 7

What Happens to Graduates ............................................. 10

Shortcomings in Monitoring and Evaluation ................................. 11

Confusing Grant Categories ............................................ 12

RECOMMENDATIONS ............................................... 13

AGENCY COMMENTS ................................................ 13

APPENDIX A: HRSA COMMENTS ...................................... 14
EXECUTIVE SUMMARY 

PURPOSE 

To determine how the Maternal and Child Health Bureau provides guidance for and 

oversight of training grants for Interdisciplinary Leadership Education Excellence in 

Caring for Children with Neurodevelopmental and Related Disabilities to assure the grants 

meet their objectives. 

BACKGROUND 

The Interdisciplinary Leadership Education Excellence in Caring for Children with 

Neurodevelopmental and Related Disabilities (LEND) is a training grant program. Its 

purpose is to train professionals who will improve the health status of infants, children, 

and adolescents, with or at risk for, neurodevelopmental and related disabilities. 

The program seeks to achieve its mission through funding graduate level, interdisciplinary 

training which produces professionals to work with special needs children. 

The Maternal and Child Health Bureau (MCHB) is part of the Health Resources and 

Services Administration, in the Department of Health and Human Services. The Maternal 

and Child Health Bureau oversees the LEND training grant program. 

The Maternal and Child Health Bureau administered 34 LEND program grants in 1998. 

The grant programs are funded in public and nonprofit universities. LEND grants to each 

institution average about $500,000 per year. In 1998, LEND grants ranged in amount 

from $300,000 to $1.2 million. 

FINDINGS 

The LEND program benefits interdisciplinary treatment for children 

LEND programs produce leaders in interdisciplinary treatment of children with 

developmental disabilities. They also play a very important role in helping to support 

university clinics serving special needs children. Further, LEND program graduates 

reduce the shortage of adequately trained people who deliver services to special needs 

children. 

MCHB Training Grants: Performance of LEND Programs 1 OEI-04-98-00090 
LEND grantees have mixed success in demonstrating leadership and tracking 

graduates 

LEND grantees have some success tracking recent graduates. However, their tracking of 

less recent graduates is spotty and some grantees collect information that is not relevant. 

Monitoring and evaluation of grantees is minimal 

MCHB does not conduct monitoring visits to grantees, and thus has little basis for critical 

decisions regarding refunding. MCHB oversight of LEND is hampered by the lack of 

systematic on-site monitoring of grantees. 

New grant categories are confusing 

MCHB has reclassified grantees as ‘Regional’ and ‘Regional and National’. This 

classification is confusing, with some grantees unsure of how to declare themselves. 

Many grantees are concerned that incorrect designation might disqualify them from 

funding. 

RECOMMENDATIONS 

MCHB should: 

Develop outcome measures for determining the success of the LEND program. 

Work with its grantees to develop more effective tracking of the LEND graduates. 

Use on-site visits to aid program oversight and in making funding decisions. 

Clearly distinguish between categories of funding. 

COMMENTS 

The HRSA concurred with our recommendations. The full text of their comments is in 

Appendix A. 

MCHB Training Grants: Performance of LEND Programs 2 OEI-04-98-00090 
INTRODUCTION 

PURPOSE 

To determine how the Maternal and Child Health Bureau provides guidance for and 

oversight of training grants for Interdisciplinary Leadership Education Excellence in 

Caring for Children with Neurodevelopmental and Related Disabilities to assure the grants 

meet their objectives. 

BACKGROUND 

The Interdisciplinary Leadership Education Excellence in Caring for Children with 

Neurodevelopmental and Related Disabilities (LEND) is a training grant program. Its 

purpose is to train professionals who will improve the health status of infants, children, 

and adolescents, with or at risk for, neurodevelopmental and related disabilities. 

The program seeks to achieve its mission through funding graduate level, interdisciplinary 

training which produces professionals to work with special needs children. The program 

focuses on health conditions of mental retardation, neurodegenerative and acquired 

neurological disorders, and multiple handicaps. The program emphasizes development of 

leadership in its trainees. 

Authorization 

Congress authorized the Maternal and Child Health Services Programs in 1935, with Title 

V of the Social Security Act. The purpose of Title V is to improve the health of all 

mothers and children consistent with applicable health status goals and national health 

objectives established by the Secretary, Department of Health and Human Services 

(DHHS). 

Administrative Responsibility 

Title V is administered by the Maternal and Child Health Bureau (MCHB) of the Health 

Resources and Services Administration (HRSA) as the Maternal and Child Health Services 

Block Grant. The Block Grant is MCHB’s principal statutory responsibility. 

The MCHB serves all mothers and children in the U.S., but places an emphasis on 

providing access to care for low-income and otherwise isolated populations. 

MCHB Training Grants: Performance of LEND Programs 3 OEI-04-98-00090 
Funding and Administration 

The Maternal and Child Health Services Block Grant was funded at $683 million in FY 

1998. Of that grant appropriation, MCHB sets aside 15 percent (about $102 million) to 

fund Special Projects of Regional and National Significance (SPRANS). 

The LEND grant program, funded at almost $18 million in FY 1998, is the largest single 

category of funding under SPRANS. 

Thirty-four (34) LEND training grants were operating in 1998. The grant programs are 

administered by public and nonprofit universities. In 1998, LEND grants ranged in 

amounts from $300,000 to $1.2 million. A typical LEND grant was about $500,000 per 

year. Each grantee provides leadership training and related administrative functions with 

their individual LEND grant. 

Organizations that receive LEND grants usually fund training that is administered by their 

University Affiliated Program (UAP). The UAP commonly administers LEND grant 

training along with training funded by other sources for related developmental disabilities. 

Beginning in 1995, the grants have been renewed on a competitive basis on a staggered 

five-year cycle. As is required in the case of multi-year funding cycles, LEND grantees 

prepare an application for continuation of funding each year. These continuations, which 

contain an annual progress report, are funded on a non-competitive basis. At the end of 

the five-year period, grantees must compete against all others interested in a LEND grant. 

Anecdotal evidence suggests there is very little turnover in the institutions receiving 

grants. 

Requirements of LEND Programs 

LEND grant programs must provide long-term training to produce professionals to work 

with special needs children. The training is usually provided at graduate and postgraduate levels, and as part of continuing education programs. The LEND grant 

programs also provide technical assistance and consultation to providers of health care 

services. Examples of program activities include: 

- Graduation of long-term trainees in a minimum of 12 disciplines.1 

- Training on State Title V programs. 

- Technical assistance to Head Start agencies, State Title V and related agencies, and 

various community-based programs. 

- Service by LEND faculty on national, regional, State, and local advisory boards. 

1

The 12 disciplines include pediatrics, nursing, public health social work, speech-language pathology, 

nutrition, audiology, occupational therapy, physical therapy, psychology, health administration, pediatric 

dentistry, and parents of children with neurodevelopmental disabilities. The last two were added in 1998. 

MCHB Training Grants: Performance of LEND Programs 4 OEI-04-98-00090 
LEND grantees also must have a LEND project director, and a faculty representing at 

least the 12 different disciplines. This allows families of children with special needs to 

receive interdisciplinary consultation at one location. The LEND grant director must be a 

board certified pediatrician. The grants have additional requirements in the areas of 

faculty qualifications, required training curriculum, faculty research, types of trainees, and 

reporting and evaluation. 

The MCHB has operated the LEND program for almost 30 years. During that time, 

MCHB has intermittently increased the number of grantees. Despite a statutory 

requirement to do so, MCHB has not evaluated LEND to determine that it is operating as 

intended. This inspection represents the first effort to do so. 

METHODOLOGY 

We purposively sampled the LEND grant programs for our inspection. We selected 17 of 

the 34 LEND grantees operating in 1998. We designed our sample to include grantees 

that represented a geographic cross section of the U.S. In addition, our sample included 

programs which have been funded since the inception of the grant program, as well as 

programs in their first funding cycle. We conducted an on-site inspection at each selected 

grant program. 

To understand program accomplishments, we used standardized data collection 

instruments for interviewing relevant officials and staff at each selected grantee. In those 

locations where training was in session, we interviewed currently enrolled trainees. We 

also interviewed recent graduates to better understand their perceptions of the usefulness 

of LEND training. On average, we interviewed 6 to 10 officials and staff at each site for a 

total of approximately 135. We also interviewed over 60 present trainees. Finally, we 

interviewed more than 30 graduates, some in person and some by telephone. 

Further, at each site we reviewed documentation on grant program funding, plans, 

operations, and accomplishments. This documentation included the application under 

which the grantee is currently funded. We also examined interim reports used to update 

MCHB on prior year accomplishments. In cases where grantees were scheduled to 

compete for the major refunding cycle, we reviewed their applications. These applications 

described their five-year accomplishments in great detail. The applications also projected 

their plans for the upcoming grant period. This information was extremely helpful to the 

inspection team in understanding the particular program. Finally, some grantees prepared 

special information for the inspection team, which we also considered. 

To ensure that LEND programs were reaching out beyond the University clinics, we 

interviewed a number of State Title V agency staff. We also contacted a number of Head 

Start Directors and their technical assistance contractors to determine their awareness of 

and interaction with LEND grantees. 

To corroborate and obtain a broader perspective on LEND program activities, we also 

interviewed several other knowledgeable parties, such as former LEND program 

MCHB Training Grants: Performance of LEND Programs 5 OEI-04-98-00090 
administrators and officials, university program administrators and officials with the 

American Association of University Affiliated Programs. Where possible we also 

interviewed senior University officials not directly associated with the grant program to 

obtain their perspectives on the program. This also gave the inspection team a sense of 

the prominence of LEND in the broader university community. 

To better understand the implications of open competition within LEND, we interviewed 

former grantee officials from programs that had unsuccessfully competed in the first open 

competition. These programs had been forced to shut down their LEND operations. In 

addition, we interviewed university officials and UAP officials who had been involved in 

these discontinued programs. From these interviews, we obtained insights and 

perspectives on closing down LEND programs. 

Finally, to ascertain program requirements and expectations, we interviewed relevant 

MCHB officials. Because of a marked turnover in MCHB staff during the time we were 

conducting this inspection, we interviewed members of both the former and present staff. 

We aggregated data from all sources and performed a qualitative analysis to compare 

LEND training grant performance to MCHB grant objectives and regulatory requirements. 

To assess MCHB decisions on funding, we analyzed program budgets, adjusting for 

inflation. In light of program mandates, we assessed MCHB decisions on program 

requirements and expansion. Finally, to assure that MCHB selection criteria were 

followed, we reviewed application requirements and grantee selections. 

_ _ _ _ _ 

We conducted data collection and analysis between July 1998 and July 1999. We 

conducted the inspection in accordance with Quality Standards for Inspections issued by 

the President’s Council on Integrity and Efficiency. 

MCHB Training Grants: Performance of LEND Programs 6 OEI-04-98-00090 
FINDINGS 

The LEND Program Benefits Interdisciplinary Treatment For 

Children 

LEND grantees produce leaders for interdisciplinary treatment for children with 

developmental disabilities 

Central to the LEND program is its stated goal to produce leaders for interdisciplinary 

treatment of special needs children. However, in its guidance, MCHB does not define 

leadership or establish standards or outcome measures by which to determine LEND’s 

success in producing leaders. 

While leadership is difficult to define, failure to do so or to establish outcome measures 

inhibits evaluation and management of the LEND program. It is clear that MCHB expects 

LEND trainees to continue serving special needs children. Therefore, LEND leadership is 

focused on a variety of professions centered around meeting the needs of such children. 

In fact, we discovered a wide range of ideas on what constituted leadership while 

interviewing LEND respondents. These definitions included teaching and publishing 

professionals. They also included researchers, service providers and program 

administrators. We used these concepts and examples as a framework for evaluating the 

LEND program. 

Leaders in providing services 

LEND graduates and trainees are in the forefront in providing services to special needs 

children. The inspection team saw a large number of LEND graduates providing state-ofthe-art services to special needs children in the university clinics. We identified LEND 

graduates who were directing a broad spectrum of innovative treatment programs, 

developing custom medical equipment and providing advocacy for special needs children. 

These clinics are a scarce and valued resource in service provision. 

LEND graduates and trainees also provide services to children in the community. One 

such site is the public schools where many LEND graduates serve as coordinators for 

services to special needs children. Typically their interdisciplinary training enables them to 

bring together a number of services appropriate to a particular child. These services may 

include audiology, speech pathology, physical therapy, nutrition and social work. 

The inspection team discovered that LEND graduates and trainees provide a variety of 

services to children who are never seen at a university clinic. Perhaps these children do 

MCHB Training Grants: Performance of LEND Programs 7 OEI-04-98-00090 
not need the level of service provided there, or are unable to travel. These children may 

live in isolated areas such as remote farming communities or Indian reservations. Without 

the LEND program, it is unlikely that some needed services could be delivered in the 

community. 

Many LEND programs also deliver services in States other than the one in which the 

program is funded. For example, a LEND program may utilize its staff or trainees to 

establish, coordinate or create new programs which serve special needs children in other 

States. These States may use the resources of the LEND grantee University Clinic. Such 

services are often designed and delivered by LEND trainees. With LEND staff and 

trainees leading the way, these services are often delivered under the auspices of the Title 

V agencies in those States. For example, each state has a Title V program for children 

with special health care needs. The state programs may coordinate services with LEND 

programs. Such programs expand the influence of LEND well beyond the university 

campus. In each case, the LEND grantee is the driving force, the leader in providing these 

services. 

Leaders in professional circles 

LEND graduates and staff also provide leadership by serving on advisory and policy 

boards for State Title V Agencies. They also serve on a large number of related 

committees, councils and boards. These bodies provide oversight and policy direction for 

a number of organizations at the international, national, regional and local levels. 

The array of such organizations is extremely broad and comprehensive, easily numbering 

in the hundreds. Some examples at the national level include: the National Cancer 

Institute, American Academy of Pediatrics, Society of Pediatric Psychology, Sickle Cell 

Disease Association of America, American Academy of Audiology, and American Society 

of Human Genetics. These are but a few examples to illustrate the influence LEND can 

have on science and public policy for special needs children. 

Leaders in program administration 

Another clear indication that the LEND grant program produces leaders is the large 

number of LEND graduates that direct and staff many of the present LEND grantee 

organizations. As a rule, the LEND grants are made to large university clinics. These 

clinics are sophisticated enterprises, housing service, research and teaching activities with 

State, regional and national scope. The clinics are the most important centers in the 

country for developing state-of-the-art treatment modalities for special needs children. In 

fact, LEND training usually represents only a small part of what they do. It is a tribute to 

LEND that the directors of these clinics are frequently former LEND trainees. These 

directors are professionals and leaders whose lives reflect a lifelong professional 

commitment to making a difference for special needs children. 

MCHB Training Grants: Performance of LEND Programs 8 OEI-04-98-00090 
LEND programs support and benefit from other activities for serving special 

needs children 

As described briefly above, one of the most striking features of the LEND program is that 

it is usually operated in close association with university clinics. The clinics deliver 

important and scarce services to special needs children. In many cases, the clinics offer 

services which are not otherwise available in the State or region. In some cases, children 

from other countries arrive at these clinics for service that is not readily available 

elsewhere. These children and their parents often reach the clinics devoid of hope that 

anything can be done to meet their needs. The inspection team heard a number of 

testimonials about how these clinics and their staffs, many of whom are funded by LEND, 

had provided the only services available anywhere to meet these special needs. 

While most of the clinics would exist regardless of LEND funding, LEND does play a 

very important role in underwriting key staffing costs. This includes paying staff salaries. 

It also includes providing trainees to work in various capacities in the clinics. Therefore, 

the LEND training grants help maintain and improve clinic services. In turn, the clinics 

offer a unique training opportunity for LEND trainees. According to many LEND grantee 

staff, the sophisticated clinic service settings provide LEND trainees unparalleled training 

opportunities, exposing them to state-of-the-art treatment modalities in addition to the 

unusual interdisciplinary approach. 

LEND funds stimulate interdisciplinary training to address shortages of 

professionals who treat special needs children 

According to several LEND grant directors, there is a shortage of adequately trained 

people to deliver services to special needs children. Many of the grantees report difficulty 

in filling their university positions, as well as practitioner positions in surrounding 

communities. In addition to testimonial evidence, we found a large number unfilled 

position announcements that had been open for a number of months. 

Further, there is a particular shortage of professionals who have received interdisciplinary 

training, widely acknowledged by professionals in the field to be the best training model. 

Individual disciplines may offer training for serving special needs children. However, the 

LEND grants were the only source identified for funding interdisciplinary training. 

In some grantees, the interdisciplinary training program provides a synergistic nucleus 

which attracts trainees who are not funded by the LEND grant. In these cases, because 

the LEND training program exists, students who are not funded by LEND may be able to 

attend and benefit from the training anyway. In this way, LEND increases training in a 

field where shortages of professionals are a continuing problem. While these trainees may 

not be tracked formally by the LEND grantees, anecdotal evidence suggests that some of 

them continue to work with special needs children. 

LEND also serves a second function in many grantee programs. It serves as a core for 

other training and research monies. These monies may come from other grants, including 

MCHB Training Grants: Performance of LEND Programs 9 OEI-04-98-00090 
university departments of individual disciplines involved in LEND training and the States 

where LEND programs reside. These departments find advantages in merging smaller 

amounts of money, usually in the form of stipend supplements, with the LEND stipends. 

In many cases this will make the LEND stipends more attractive to the outstanding 

student. 

LEND Grantees Have Mixed Success In Demonstrating 

Leadership and Tracking Graduates 

Factors affecting leadership 

The standard model of professional leadership is one in which appropriate education is 

followed by professional experience, during which leadership activities may accede 

progressively over time This means that LEND programs which purport to produce 

leaders must either produce them more immediately than the norm or keep track of 

graduates until they become leaders. Otherwise LEND programs will not know if they are 

meeting their objective. LEND grantees claim to do both. 

Several factors help determine whether or when a LEND graduate becomes a leader. 

Grantees noted that some LEND graduates do become leaders immediately upon 

graduation, while others may never do so. 

One such determining factor is the discipline of the LEND graduate. Within the required 

LEND disciplines, professional training and credentials vary widely. These differences are 

a strength of the LEND program. For example, some trainees are medical doctors or 

PhDs doing post-doctoral work in other disciplines. Trainees with such advanced 

education are more likely to move directly in leadership positions than trainees seeking 

master’s degrees. 

A second factor determining the likelihood of immediate leadership is the level of 

professional experience graduates have. For example, some LEND trainees are postdoctoral students who came into the training from leadership positions. They complete 

LEND training either to return to their existing position or go into other leadership 

positions. Most LEND trainees, however, enter the program with little experience with 

special needs children. Such trainees are likely to leave the LEND training program to go 

into entry level professional positions, such as a school nurse. For these trainees, 

leadership may come later in their careers. 

A third factor in determining whether a LEND graduate becomes a leader is the 

geographic location of their position following their LEND training. To illustrate, a 

practitioner who has LEND training and is located in a rural setting, with a shortage of 

health resources, may become a leader almost by default. We found instances of LEND 

graduates with very little experience beyond their training, who are serving in a variety of 

leadership roles in their communities. According to some LEND officials, these graduates 

MCHB Training Grants: Performance of LEND Programs 10 OEI-04-98-00090 
would not function as leaders in urban centers where practitioners with more credentials 

and greater experience serve in those roles. 

Tracking graduates 

MCHB requires LEND grantees to track trainees. Tracking is important for several 

reasons. The first is to ascertain the extent to which trainees remain in the field of helping 

special needs children. Another is to ascertain the extent that LEND trainees assumed 

positions of leadership in their fields. Finally, tracking could provide valuable feedback on 

the impact of LEND training. Such information can be very useful in planning, directing, 

monitoring, and evaluating individual LEND training programs. In fact, this information 

comprises much of the basic data needed to evaluate the leadership aspect of LEND. 

LEND grantees reported mixed success in tracking their graduates as required. However, 

none of the programs we visited demonstrated particular success in tracking. As might be 

expected, tracking of recent graduates is relatively effective, while over time tracking 

becomes more difficult. Unfortunately, grantees lose track of their graduates later in their 

careers when they are more likely to be assuming professional leadership roles. 

In some cases, tracking systems are not capturing relevant information, despite the fact 

that they had maintained contact with many of their graduates. For example, some 

grantees collect no information on the position or duties of the graduate. Instead they had 

collected information on the graduate’s employer such as “school system” or “State 

Government.” From such information, it is impossible to ascertain whether the graduate is 

working as a leader with special needs children. While we accepted a variety of evidence 

that LEND produces leaders, improved graduate tracking could better demonstrate this. 

MCHB Monitoring and Evaluation of Grantees Is Minimal 

MCHB does not conduct monitoring visits to grantees. MCHB has not evaluated LEND 

programs despite a requirement to do so. LEND training programs are very complex and 

diverse. Without direct on-site monitoring and evaluation of program activities and 

results, MCHB has little basis for critical decisions regarding refunding. This lack of 

insight also hinders MCHB as they assess changes in program policy and operations 

decisions. 

With the absence of on-site monitoring, MCHB places the future of individual training 

grant programs solely in the hands of grant writers and grant reviewers. Grantees 

expressed concern that they would not get full credit for their accomplishments. Instead, 

they felt they might lose out to other institutions with no track record, but the ability to 

write better applications. 

MCHB staff acknowledge the difficulty of administering grants of this complexity without 

first-hand knowledge of grantee operations and performance. 

MCHB Training Grants: Performance of LEND Programs 11 OEI-04-98-00090 
New Grant Categories Are Confusing 

Many grantees expressed confusion over MCHB’s new grant categories — specifically 

“Regional Significance” and “Regional and National Significance.” These category 

designations are intended by MCHB to distinguish between large training programs which 

have an expanded scope and focus on a regional and national level, and smaller programs 

which focus only at the regional level. 

“Regional Significance” and “Regional and National Significance” designated programs 

are subject to different funding limitations. Programs of Regional Significance may not 

request more than $450,000 per year. Programs of National Significance, however, may 

qualify for funding significantly above $450,000. 

While potentially useful for strategic planning purposes, the designations were difficult to 

understand and subject to individual interpretation. To illustrate, for determining their 

refunding status, MCHB instructed LEND grantees to self-declare their program category. 

Many grantees expressed concern that they might designate their program incorrectly and 

disqualify themselves from all funding. 

MCHB Training Grants: Performance of LEND Programs 12 OEI-04-98-00090 
RECOMMENDATIONS 

MCHB should develop measures for determining the success of the LEND 

program. 

In order to comply with requirements to evaluate the LEND program, MCHB should 

specify measures for determining the success of each LEND grantee. Such measures 

could include a definition or set of definitions of leadership. It could also establish a 

standard set of proxies for leadership to be used in evaluation. 

MCHB should work with grantees to develop better methods for tracking 

graduates 

To better determine the extent to which the LEND graduates become leaders meeting the 

needs of children with special needs, MCHB should collaborate with its grantees to 

develop and disseminate better ways to track graduates. The more effective the tracking, 

the better able LEND will be to make the case that they are producing leaders in this field. 

Use on-site monitoring to aid in making funding decisions 

Site visits would enable MCHB to better access grantee operations and results. The onsite monitoring could be similar to the regular site monitoring currently employed for 

University Affiliated Programs. Through such monitoring, MCHB could make more 

informed funding determinations. 

Clarify ‘Regional’ and ‘Regional and National’ grant funding categories 

Because grantees can lose their chance of funding if they mis-designate their program, the 

current confusion over the funding designations has potentially serious ramifications for 

LEND training programs. MCHB should consult with grantees to develop a better way 

for distinguishing between categories of grants. 

AGENCY COMMENTS 

HRSA concurred with our recommendations. Their comments are in Appendix A. 

13 
APPENDIX A 

14
APPENDIX A 

15
APPENDIX A 

16