```
Early Childhood Programs: Local Perspectives on Barriers to Providing
Head Start Services (Letter Report, 12/21/94, GAO/HEHS-95-8).

To gather information on problems that Head Start programs face in
trying to provide services, GAO surveyed a sample representing about 46
percent of all Head Start programs nationwide. Head Start program
directors identified three barriers as significantly affecting their
ability to provide services to children and families: insufficient
qualified staff to meet the complex needs of children and families; a
limited availability of health professionals in the community willing to
help Head Start staff in providing services; and difficulties in getting
suitable facilities at reasonable costs.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-8
     TITLE:  Early Childhood Programs: Local Perspectives on Barriers to 
             Providing Head Start Services
      DATE:  12/21/94
   SUBJECT:  Children
             Disadvantaged persons
             Head-start programs
             Preschoolers
             Child care programs
             Education program evaluation
             Personnel recruiting
             Funds management
             Aid for education
             Teacher salaries
IDENTIFIER:  AFDC
             Medicaid Program
             
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Cover
================================================================ COVER

Report to the Chairman, Subcommittee on Children, Family, Drugs and
Alcoholism, Committee on Labor and Human Resources, U.S.  Senate

December 1994

EARLY CHILDHOOD PROGRAMS - LOCAL
PERSPECTIVES ON BARRIERS TO
PROVIDING HEAD START SERVICES

GAO/HEHS-95-8

Early Childhood Programs

Abbreviations
=============================================================== ABBREV

  ACF - Administration for Children and Families
  AFDC - Aid to Families with Dependent Children
  CAA - Community Action Agency
  CDA - Child Development Associate Certificate
  HHS - U.S.  Department of Health and Human Services
  OMB - Office of Management and Budget
  PIR - Program Information Report

Letter
=============================================================== LETTER

B-252284

December 21, 1994

The Honorable Christopher J.  Dodd
Chairman, Subcommittee on Children,
 Family, Drugs and Alcoholism
Committee on Labor and Human Resources
United States Senate

Dear Mr.  Chairman: 

Head Start, a $3.5 billion program currently serving nearly 750,000
children each year, has been the centerpiece of federal early
childhood programs for almost 30 years.  Head Start is a major factor
in ensuring that disadvantaged children start school ready to
learn.\1 However, recent concerns have been raised about the uneven
quality of Head Start programs. 

This report responds to your request to identify

barriers that Head Start staff believe limit their ability to provide
quality services, the extent to which staff believe programs
experience these barriers, and the techniques or approaches programs
have used to overcome these barriers; and

how local Head Start programs use Quality Improvement Funds to
enhance and strengthen service quality.\2

To gather information on problems that Head Start programs face in
trying to provide services, we surveyed a nationally representative
sample of 870 Head Start grantees and delegates from a universe of
1,898 programs.\3 Directors of these programs provided information
for school year 1992-93 on staff salaries and fringe benefits,
training, facilities, service providers in their communities, and
funding--including the use of Quality Improvement Funds.  Our overall
survey response rate was 76 percent.  (See app.  II for a full
description of our survey methodology and app.  III for a copy of our
survey instrument.)

--------------------
\1 Goals 2000:  Educate America Act (P.L.  103-227) states that by
the year 2000 all children in America will start school ready to
learn. 

\2 The Head Start Expansion and Quality Improvement Act of 1990
authorized set-aside funds to be used by programs to enhance and
strengthen the quality of Head Start services. 

\3 The 870 grantees and delegates in our survey represent
approximately 46 percent of all Head Start programs nationwide. 
Because only a portion of the universe was selected for analysis,
each estimate has a measure of uncertainty, or sampling error,
associated with it.  The size of the sampling error reflects the
precision of the estimate; the smaller the sampling error, the more
precise the estimate.  Sampling errors for the estimates in this
report were calculated at the 95-percent confidence level. 

   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Head Start program directors identified three barriers as
significantly affecting their ability to provide services to children
and families.  Over 90 percent of the Head Start directors responding
to our survey reported experiencing at least one of the following
barriers: 

insufficient qualified staff to meet the complex needs of the
children and families,

a limited availability of health professionals in the community
willing to help Head Start staff in providing services, and

difficulties getting suitable facilities at reasonable costs.\4

More specifically, over 86 percent of Head Start directors reported
insufficient qualified staff to provide one or more types of
services:  education, medical, dental, mental health, disability,
nutrition, parent involvement, and social services.  According to the
directors, the areas most frequently cited as needing more qualified
staff were social services, mental health, and parent involvement. 
Low salaries hamper local Head Start programs' ability to hire
qualified staff, particularly teachers.  On average, Head Start
teachers typically earn less than teachers with similar positions in
the community. 

About 25 percent of the directors indicated difficulty in getting
help from health professionals in the community to assist them in
providing services.  Directors attributed the lack of available
health providers and providers' unwillingness to donate services or
accept Medicaid as the main reasons why programs had health service
related difficulties.  About two-thirds of the directors reported
difficulties finding space.  They cited lack of suitable space,
licensing requirements, and high renovation costs as the major
obstacles. 

Program directors reported trying a variety of techniques, sometimes
involving Quality Improvement Funds, to help overcome or eliminate
some of these barriers.  Directors interviewed during our site visits
said that they work closely with community medical facilities to
ensure that children receive health services, and they negotiate with
local public schools for unused space.  In addition, survey results
showed that the primary use of Quality Improvement Funds during
school year 1992-93 was to increase staff salaries and fringe
benefits and generally to recruit and retain qualified staff. 

--------------------
\4 Unless otherwise cited, references to Head Start directors
reporting a particular barrier are based on survey results. 

   BACKGROUND
------------------------------------------------------------ Letter :2

Since its inception in 1965, Head Start has provided a wide range of
services to over 13 million children and their families nationwide. 
Head Start is targeted by law to children from poor families, and
Head Start regulations require that 90 percent of the children
enrolled in each program be low income.\5 All programs must meet
performance standards, established by the Department of Health and
Human Services (HHS), in the areas of education and medical, dental,
nutritional, mental health, and social services.\6

Head Start programs work with various sources in their communities to
provide these services.  For example, some programs coordinate with
Public Health agencies to obtain health services, while other
programs contract with local physicians.  Another essential part of
every program is the involvement of parents in parent education,
program planning, and operating activities. 

Head Start is administered by HHS' Administration for Children and
Families (ACF).  Services are provided at the local level by public
and private nonprofit agencies that receive their funding directly
from HHS.  These include public and private school systems, community
action agencies, government agencies, and Indian tribes.  In fiscal
year 1993, grants were awarded directly to about 1,400 local agencies
(grantees), and the national average Head Start cost per child was
$3,758.  A grantee may contract with one or more other public or
private nonprofit organizations (delegates) in the community to run
all or part of its Head Start program.  Grantees may choose to
provide center-based services, home-based services, or a combination
of both. 

Although Head Start is authorized to serve children at any age before
the age of compulsory school attendance, most children enter the
program at age four.  To serve more children, the federal government
has increased Head Start funding annually from 1989 through 1994.  In
total, increased funding provided services for an additional 263,000
children over the 5-year period.  (See app.  I for enrollment and
funding information.) For fiscal year 1995, $3.5 billion was made
available for the Head Start program, an increase of $208 million
over fiscal year 1994 funding.  Despite expansion efforts, only 17
percent of eligible three-year olds and 41 percent of eligible
four-year olds attended Head Start in fiscal year 1993.\7

In addition to providing funds to increase the number of children
served, the Congress has increased emphasis on the quality of program
services.  In 1990, the Congress passed the Head Start Expansion and
Quality Improvement Act, which reauthorized Head Start and also set
aside funds to be used by programs to enhance and strengthen the
quality of Head Start services.  The legislation provided that 25
percent of the increase over the previous year's allocated funds be
designated for quality improvements.  Programs must spend at least
one-half of the Quality Improvement Funds to increase staff salaries
or fringe benefits.  The remainder of the funds may be spent on
transportation, hiring additional staff, nonstructural improvements
to facilities, and training. 

Despite the emphasis on quality, some early childhood experts and the
Advisory Committee on Head Start Quality and Expansion are still
concerned about the uneven quality of some Head Start programs.\8
While research shows a positive correlation between high-quality
early childhood programs and positive outcomes on students, most of
this research was conducted on programs that have far more resources
than the typical Head Start program.\9 In addition, a 1993 report by
the HHS Office of Inspector General indicates that programs are
facing difficulties in meeting performance standards.\10

This report, based on a random sample of 80 programs nationwide,
showed that only 54 percent of children in the programs received
complete medical screening, and 47 percent of the families with
identified social service needs had all or most of their needs met. 

The environment in which children live today has changed greatly
during the years.  About one out of every five children in the United
States today lives in poverty, and, for minority children, the
segment is almost twice as large--40 percent.  Between 1980 and 1990,
the number of poor preschool-aged children increased by 28
percent--from 1.1 million to 1.4 million.\11 Research has shown that
family income is the most important predictor of children's success
or failure in school; children from low-income families are more
likely to experience difficulties.  Children in poverty are at
greater risk for developmental problems resulting from poor maternal
nutrition, undeveloped caregiving skills, drug abuse, and unstable
family setting. 

Recent research shows that environmental deficits--such as too little
cognitive stimulation and inadequate health care--undermine
disadvantaged children's development and affect their school
performance.  A 1991 study of children whose families were recipients
of Aid to Families with Dependent Children (AFDC), the federal
assistance program, found that two-thirds of these children did not
live in home environments that stimulated their cognitive growth and
did not receive sufficient emotional support from their parents.\12
The study revealed similar findings for the children of low-income
families that were not receiving AFDC. 

Other factors associated with low income of families--minimal parent
education attainment and single parenting--increase children's risk
of doing poorly in school.  The parents of poor preschool-aged
children are less educated than in the past.  Between 1980 and 1990,
the number of families in which neither parent had completed high
school increased by 20 percent.  In addition, during the 1990-91
operating year, more than 50 percent of Head Start families were
headed by a single parent. 

Given these changes in the environment, it is not surprising that
Head Start staff encounter children and families with more complex
problems requiring urgent and extensive intervention.  According to a
1989 report by the HHS Inspector General, the major family problems
encountered by Head Start staff were substance abuse, child abuse,
domestic violence, lack of parenting skills on the part of teenage
parents, and crime-infested, inadequate housing.\13 About 84 percent
of the Head Start grantees surveyed by the Inspector General reported
increased demands on staff time for such activities as one-to-one
counseling, assistance to families, and dealing with troubled
children in the classroom. 

--------------------
\5 The Head Start program uses the Office of Management and Budget
(OMB) poverty income guidelines to determine a child's eligibility
for services--$14,350 for a family of four in 1993. 

\6 Head Start Program Performance Standards (45 C.F.R.  1304). 

\7 Early Childhood Programs:  Many Poor Children and Strained
Resources Challenge Head Start (GAO/HEHS-94-169BR, May 17, 1994),
p.13. 

\8 The Secretary of HHS initiated a bipartisan task force, the
Advisory Committee on Head Start Quality and Expansion, to review the
Head Start program and make recommendations.  The committee issued a
report in December 1993 titled Creating a 21st Century Head Start. 

\9 For example, the most cited study on the benefits of early
childhood education (High/Scope Education Research Foundation study
of the Perry Preschool program, 1980) spent almost twice as much per
child as expenditures for Head Start programs.  In addition, the
Perry Preschool had a low child-to-staff ratio, and almost all
teachers had advanced degrees in early childhood education. 

\10 Evaluating Head Start Expansion Through Performance Indicators,
HHS Office of Inspector General (OEI-09-91-00762) (Feb.  1993), pp. 
8-13. 

\11 Poor Preschool-Aged Children:  Numbers Increase but Most Not in
Preschool (GAO/HRD-93-111BR, July 21, 1993), p.  2. 

\12 Nicholas Zill, Kristin A.  Moore, Ellen Wolpow Smith, and others,
The Life Circumstances and Development of Children in Welfare
Families:  A Profile Based on National Survey Data, Child Trends,
Inc., (Washington, D.C.:  1991), p.  19. 

\13 Dysfunctional Families in the Head Start Program:  Meeting the
Challenge, HHS Office of Inspector General, (OAI-09-89-01000) (Nov. 
1989), p.  i. 

   HEAD START DIRECTORS SAID
   STAFFING PROBLEMS HAMPERED
   SERVICE PROVISION
------------------------------------------------------------ Letter :3

Survey results show that most Head Start directors believe they have
insufficient qualified staff to meet the needs of the children and
families they serve.  The lack of staff leads to large caseloads,
which researchers indicate may jeopardize service quality.  Moreover,
many program directors reported that low salaries hampered their
ability to hire qualified staff.  Directors also reported that their
staff need more training, particularly in the areas of mental health,
disabilities, parent involvement, and social services.  Through
research and interviews, we found that a lack of minimum staff
qualifications and maximum caseload requirements also contributed to
staffing problems.  To help overcome these problems, directors
reported increasing salaries and fringe benefits and providing more
opportunities for staff training and development. 

      HEAD START DIRECTORS
      REPORTED A LACK OF QUALIFIED
      STAFF
---------------------------------------------------------- Letter :3.1

According to our survey data, more than 86 percent of Head Start
directors believe that at least one type of Head Start service in
their program lacks enough qualified staff.  In each of two areas,
social services and mental health services, at least 60 percent of
the directors reported that they had insufficient qualified staff. 
(See fig.  1.)

   Figure 1:  Programs Reporting
   Insufficient Staff by Type of
   Service

   (See figure in printed
   edition.)

A lack of qualified staff was a problem for programs of all sizes and
all geographic locations.  For example, 84 percent of directors from
urban programs and 87 percent of directors from rural programs
reported insufficient qualified staff.  Similarly, directors from
small, medium, and large programs all reported a lack of qualified
staff--87 percent, 90 percent and 82 percent, respectively.\14

Insufficient staff can lead to large caseloads, which may jeopardize
Head Start's ability to provide quality services.  Research shows
that over half of the Head Start programs have average social service
caseloads of 100 or more--at least three times the HHS recommended
level of 35 families per social worker.\15 Similarly, about one-third
of the programs have average health and parent involvement caseloads
of 250 or more.  Several researchers have reported that large
caseloads limit the number of home visits and family needs
assessments staff can conduct.\16 While Head Start requires a minimum
of two home visits and one family needs assessment per year, HHS
guidance suggests that more family contact is beneficial.  As Head
Start programs expand to serve more children and families, caseloads
of already overworked staff may get even larger, further jeopardizing
service quality. 

--------------------
\14 We defined small programs as those with less than 150
participants, medium programs as those with 151 to 350 participants,
and large programs as those with more than 350 participants. 

\15 Caseload figures prepared by Pelavin Associates, Inc.  based on
data from the 1992 Program Information Report and the HSCOST system
as reported in Head Start Staffing Data, June 1993. 

\16 Edward Zigler and Susan Muenchow, Head Start:  The Inside Story
of America's Most Successful Educational Experiment, (New York: 
BasicBooks, 1992), p.  217. 

      HEAD START DIRECTORS
      REPORTED THAT LOW SALARIES
      HAMPER THEIR ABILITY TO HIRE
      QUALIFIED STAFF
---------------------------------------------------------- Letter :3.2

One reason why programs lack enough qualified staff is that low
salaries reportedly hamper their ability to hire qualified staff. 
Survey respondents indicated that their salaries are often lower than
those other employers offer to individuals with similar
qualifications and experience their communities.  In every service
area except nutrition, at least 50 percent of the directors reported
that the salaries paid to their staff were lower.  (See fig.  2.) Of
the directors reporting that their salaries were lower than those
offered by other employers in their community, at least 75 percent
said it hampered their ability to hire qualified education staff,
social service staff, and parent involvement staff. 

   Figure 2:  Programs Reporting
   Lower Salaries by Type of
   Service

   (See figure in printed
   edition.)

On average, Head Start teachers typically earn lower salaries than
others with similar positions in the community.  A 1990 Department of
Education study performed by Mathematica Policy Research Inc.  showed
that the average hourly wage for Head Start teachers was $9.67, or
$4.73 less than the average hourly wage of public school-based child
care center teachers ($14.40).  According to HHS data, the average
salary for the most tenured Head Start teachers was $15,039 in 1992,
while the average salary for the least tenured teachers was $12,077. 
Directors we interviewed attributed low salaries to the following: 

Despite recent increases, salaries have been low for so long that it
will likely take quite a while for them to catch up to competitive
levels. 

Because Head Start staff may lack certain qualifications, they are
more likely to earn less than other professionals in their fields. 

While Head Start directors generally have a fair amount of discretion
on salary decisions, some are not taking full advantage of this
discretion.  Several directors from programs administered by
community action agencies indicated they were not allowed to raise
the salaries of Head Start staff because it would not be fair to the
staff of the other community action agency's programs. 

Low teacher salaries appear to be less of a problem in Head Start
programs administered by public schools because in these programs
Head Start teachers usually receive the same wages as other teachers
in the school system.  However, higher wages may lead to other
problems.  For example, one large program we visited is currently in
the process of leaving the local school district because it could not
afford to pay the salaries negotiated by the teachers' union.\17

--------------------
\17 Letter to Senator Paul Simon (GAO/HEHS-93-1100, Aug.  25, 1994). 

      HEAD START DIRECTORS
      REPORTED NEED FOR ADDITIONAL
      STAFF TRAINING
---------------------------------------------------------- Letter :3.3

In every area, many directors reported a need for additional training
to better prepare their staff to handle the multiple problems of
dysfunctional families.  In both the mental health and disabilities
areas, nearly half of the directors reported a need for more staff
training, and, in each of the other areas, at least 30 percent of the
directors reported a similar need.  (See fig.  3.) Head Start
directors typically attributed the lack of training to (1) the
unavailability of needed courses and (2) insufficient tailoring of
available courses to meet the specific training needs of their staff. 

   Figure 3:  Programs Reporting
   Insufficient Training by Type
   of Service

   (See figure in printed
   edition.)

      OTHER FACTORS CONTRIBUTING
      TO STAFFING PROBLEMS
---------------------------------------------------------- Letter :3.4

We found that HHS does not require minimum educational qualifications
for its nonteaching staff.  While a program may have an adequate
number of staff, these staff may not be qualified to handle the
complex needs of the children and families they serve.  The 1990 Head
Start Amendments require each classroom to have at least one teacher
with a minimum of a Child Development Associate (CDA) certificate or
equivalent.  However, similar qualifications are not required for
staff providing health or social services. 

Several Head Start staff we interviewed emphasized the need for
requirements, similar to the CDA, for health and social service staff
because of the complex needs these staff are trying to address. 
Others believe that staff should have at least a bachelor's or
master's degree in their field.  However, minimum educational
qualifications would likely interfere with Head Start's goal of
providing parents with opportunities to participate in the program as
paid employees or volunteers. 

We also found that, with the exception of teaching staff, HHS does
not have maximum caseload requirements for other Head Start staff. 
HHS recommends, but does not require, a caseload of 35 families per
social service worker.  As stated above, caseloads are well above
this level.  Without caseload requirements, no mechanism exists for
holding local programs accountable for their caseloads.  However,
reducing caseloads would result in either serving fewer children or
hiring more staff, which would increase operating costs. 

      EFFORTS TO OVERCOME STAFFING
      PROBLEMS
---------------------------------------------------------- Letter :3.5

Many Head Start directors said that they are increasing salaries and
benefits and providing more opportunities for staff training and
development to help attract and retain qualified staff.  They
reported spending the majority of their Quality Improvement Funds on
increasing salaries and fringe benefits.  (See p.  20 for additional
information on Quality Improvement Funds.) Further, directors said
that they are providing additional opportunities for staff training
and development to help reduce staffing problems.  To identify
specific staff training needs, many directors said that they have
started conducting periodic training needs assessments.  To help meet
the identified needs, many directors reported coordinating efforts
with local training providers, such as community colleges, and
conducting in-house training sessions. 

      HHS ACTIONS TO ADDRESS
      STAFFING PROBLEMS CITED BY
      HEAD START DIRECTORS
---------------------------------------------------------- Letter :3.6

HHS officials agreed that staffing problems have hampered the ability
of local Head Start programs to provide services.  To help with
staffing problems and improve program quality, the Department
provided $344 million in discretionary funds to local programs in
fiscal year 1994.\18

HHS urged programs to consider the following areas in applying for
funds: 

Does the local program have sufficient staff to meet the increasing
complex needs of Head Start families, particularly in the service
areas of social services and parent involvement?  (The Department
cited the Advisory Committee's recommended goal of a ratio of at
least 1:35 for staff who work directly with families.)

Are staff wages reasonable and competitive, and do programs provide
adequate fringe benefit packages in order to attract and retain
qualified and competent staff? 

Do staff have access to training that will help them better meet the
needs of the families they serve? 

While HHS lacks specific information on how individual programs
improved quality, an additional 4,000 staff were hired by local Head
Start programs this year, many of which were family service workers
who provide social services to children and families.  Further, each
Head Start staff received at least a 2.7-percent salary increase. 

In addition, the officials recognized that nonteaching Head Start
staff do not have minimum qualifications, which can impact quality. 
They stated that this issue will be addressed in fiscal year 1995 as
a result of requirements in the 1994 Head Start reauthorization
legislation to update staffing patterns and identify competency-based
credit (similar to teacher CDA requirements) for family service
workers providing social services. 

--------------------
\18 This amount was in addition to the legislatively mandated
set-aside amount of $119 million to be used for quality improvements. 

   SOME HEAD START PROGRAMS FACE
   DIFFICULTIES IN GETTING
   SERVICES FROM LOCAL HEALTH
   PROFESSIONALS
------------------------------------------------------------ Letter :4

An important premise of Head Start has always been community
involvement in helping meet the needs of children and their families. 
However, some Head Start directors reported that it is difficult to
get support from the community to ensure children's required
services.  About one-fourth of Head Start programs, accounting for
over 150,000 children, had difficulty getting help from local health
professionals in the community.  Directors of large programs reported
difficulty more often than directors of small ones--29 percent of
large programs compared to 14 percent of small programs.  However,
statistically significant differences were not apparent between urban
and rural programs. 

Head Start directors reported that these difficulties were due to (1)
the lack of available resources in the community and (2) the
reluctance of health professionals to accept Medicaid reimbursements
to treat Head Start children.\19 In addition, some directors we
interviewed told us that health professionals are less willing to
donate services than they were in the past.  To ensure access to
health services, some programs have had to pay directly for services,
develop in-house expertise, or transport children long distances to
services. 

Head Start Performance Standards require programs to provide a
thorough health screening for each child enrolled in the Head Start
program.  Health screenings include assessments of dental,
disability, medical, and mental health needs.  While many programs
provide initial assessments, they typically rely on the community for
the more complicated screenings and much of the follow-up care. 

A 1993 HHS Inspector General report showed that, while programs
completed a high percentage of medical and dental assessments, a much
smaller percentage provided the full range of assessments.\20 For
school year 1991-92, only 54 percent of children received all
required health screening assessments.  In addition, the report
showed that children did not receive all the necessary follow-up
treatment.  Only 76 percent of Head Start children had all their
medical needs met, and 67 percent of children had all their dental
needs met.  The Inspector General also reported that directors from
these programs cited diminishing community support as a major concern
in meeting program requirements.\21

Nearly all of the 25 percent of directors who, in our survey,
reported difficulties in getting help from the local community
attributed this to the unavailability of health professionals. 
Several directors we interviewed said that health professionals do
not open practices in some of the poorer and more rural areas.  One
director attributed this to the low wages offered in rural
communities.  Another director from a rural area said she found a
dentist in town willing to provide screenings, but she could not find
one to provide follow-up care.  About 30 percent of the children in
her program require follow-up treatment each year with a pediatric
dentist.  These children, accompanied by a parent, must be bused 50
miles for such dental care. 

Another problem Head Start directors reported is the reluctance of
health professionals to accept Medicaid payments for Head Start
children.  Over 75 percent of the directors having difficulty getting
community support reported a reluctance by medical and dental
providers to accept Medicaid.  Head Start directors we interviewed
attributed these difficulties to the added expense of processing
Medicaid paperwork and delays in reimbursement for services.  One
director told us that a local dentist's office said that if it
accepted Medicaid patients it would have to hire a full-time person
just to handle the paperwork involved in getting reimbursed for
services. 

The Physician Payment Review Commission also found that low
reimbursement for Medicaid services and paperwork and billing
concerns were the major reasons why medical providers are reluctant
to accept Medicaid patients.\22 The Commission found that only 65
percent of physicians who were accepting new patients agreed to take
Medicaid patients in 1992. 

Further, some directors we interviewed saw a decline in the number of
health professionals willing to donate services to Head Start
children and their families.  In the past, programs usually had
several sources of free or low-cost services, and people were more
willing to pull together to help the poor.  Several directors we
interviewed noted that health professionals have become overextended
because of greater needs in the community as a whole.  For example,
several directors said that it is difficult to get a contract for
mental health services because of increasing demand.  As a result,
their clients face waiting lists for mental health services.  In
addition, because of recent increases in Head Start funding, some
health professionals perceive Head Start as a wealthy program today
and now expect to receive payment for their services. 

To cope with the lack of community support, Head Start directors
tried various approaches, including

establishing staff positions to provide in-house screening and
counseling services,

paying directly for health services,

transporting children long distances for services,

making arrangements with university medical centers to provide needed
health services,

coordinating with local school districts for health screening,

creating "shared" staff positions for disability services with other
agencies because the pool of disability specialists is limited,

securing donations from corporations and local businesses for
substance abuse programs and family support groups, and

obtaining agreements with mobile dentists who bring equipment to the
Head Start center to provide dental screenings. 

While some of these methods help to ensure service provision, they
may raise Head Start's costs for providing services to children and
their families. 

--------------------
\19 The reluctance of health professionals to accept Medicaid is a
problem because many Head Start children qualify for Medicaid
coverage. 

\20 Evaluating Head Start Expansion Through Performance Indicators,
p.  8. 

\21 Head Start Expansion:  Grantee Experiences, HHS Office of
Inspector General (OEI-09-91-00760) (Washington D.C.:  1992), p.  10. 

\22 Annual Report to Congress, Physician Payment Review Commission
(Washington D.C.:  1994).  The Commission reports annually on issues
related to health system reform as well as Medicare and Medicaid
policy. 

         HHS ACTIONS TO ADDRESS
         PROBLEMS IN GETTING HELP
         FROM HEALTH PROFESSIONALS
-------------------------------------------------------- Letter :4.0.1

HHS officials recognize that some programs continue to have
difficulty getting services from local health professionals, which
can impact Head Start's ability to provide services to all children
and families.  To help local programs get cooperation from local
health care professionals, HHS officials told us that they are
exploring the feasibility of advance payment to health care providers
for services covered under Medicaid.  If Head Start is allowed to
provide advance payment, the Department believes more health
providers would be willing to accept Medicaid. 

In addition, the Department plans to emphasize coordination at the
national level with various health care groups in fiscal year 1995. 
HHS officials believe that developing better coordination with health
care groups at the national level will result in better coordination
and commitment at the local level in providing health services to
Head Start children and families. 

   HEAD START DIRECTORS REPORTED
   DIFFICULTIES FINDING SUITABLE
   SPACE
------------------------------------------------------------ Letter :5

Although providing appropriate facilities is an essential component
of program quality, finding such space is difficult for many Head
Start programs.  On the basis of our survey results, we estimate that
about 1,300 programs tried to rent or purchase space in school year
1992-93, and about two-thirds of those programs had difficulty doing
so.  Programs nationwide had difficulties finding space, regardless
of whether they were in urban or rural areas. 

Survey respondents cited a limited number of facilities suitable for
preschool-aged children located in the areas that Head Start serves. 
When they did find space, respondents said that they struggled to
meet licensing requirements or pay for costly renovations needed to
upgrade facilities into suitable Head Start classrooms.  According to
Head Start officials we interviewed, difficulties in finding space
impact services for some children and impede Head Start efforts to
expand services to more children.  To ensure that suitable classroom
space is found, survey respondents told us they have coordinated with
local school districts, federal agencies, and other community
resources. 

      SUITABLE SPACE IN THE
      COMMUNITY IS LACKING
---------------------------------------------------------- Letter :5.1

According to survey results, about 95 percent of the directors
reporting difficulties renting space during school year 1992-93 cited
lack of available space in their community as a reason.  When rental
space is available, often it is not suitable for Head Start needs. 
Head Start Performance Standards require buildings to be located in
safe environments for children and have appropriate playground space. 
In addition, buildings must be functional for early childhood
learning, which includes sufficient space, lighting, ventilation,
heat, and other health and safety standards.  Finally, buildings must
be located in an area that is zoned for an early childhood program. 
According to Head Start officials we interviewed, few available
buildings, especially in high poverty areas, meet these requirements. 

Before 1992, Head Start programs were prohibited by law to build or
purchase their own facility.  As a result, programs either leased
space in the community or relied on local landlords to donate space. 
However, according to Head Start experts, many churches and schools
where Head Start centers have traditionally been located are
reclaiming previously donated space, forcing many Head Start programs
to look for alternative space in the community. 

      LENGTHY PROCESS OF MEETING
      LICENSING REQUIREMENTS
      DELAYS PROGRAMS
---------------------------------------------------------- Letter :5.2

While licensing requirements for facilities are important to ensure a
high-quality Head Start program, meeting the various licensing
requirements can be lengthy and difficult.  About 80 percent of the
directors that reported difficulty renting space cited licensing
requirements as a reason.  According to program directors we
interviewed, licensing requirements are lengthy and burdensome and
have delayed the opening of new centers and forced other centers to
relocate. 

For a Head Start facility to be licensed, it must meet a variety of
federal, state, and local child care requirements, as well as county
and municipal fire and safety codes.  A Head Start director in one
state we visited said that the licensing process in her area
generally takes up to 9 months and requires approval from four
different city agencies.  Another director we visited told us that it
took over 2 years to get her center licensed.  She said the lengthy
delays and paperwork made it difficult for her to negotiate with
landlords to secure space. 

Even after centers are licensed, meeting licensing requirements is a
continual process.  Programs are periodically--as often as once every
2 years--reviewed to ensure that they continue to meet licensing
requirements.  Head Start directors we interviewed told us that
licensing requirements often change from year to year, forcing some
programs to look for alternative space.  In one state, Head Start
officials told us recent changes to state licensing requirements,
including specific requirements for stairway size and room
ventilation, will force many Head Start programs to vacate their
space and relocate.  Another director told us her program was forced
to vacate a newly renovated center because of a new local fire code
that restricts Head Start from using two-story buildings.  This
program must find facilities for almost 500 children with few space
alternatives available.  While Head Start directors we interviewed
are concerned that meeting licensing requirements may increase the
cost of finding and operating Head Start facilities, they also agree
that a high-quality and safe learning environment is an important
goal of Head Start. 

      RENOVATING AVAILABLE SPACE
      IS COSTLY
---------------------------------------------------------- Letter :5.3

Even when space is available, sometimes renovation costs are so high
the space cannot be used.  Directors in over 90 percent of the
programs that had difficulties renting cited high renovation costs as
a reason.  Many of the buildings in areas that Head Start serves have
inadequate plumbing, low ceilings, poor lighting, and asbestos and
lead paint problems, which are very costly to fix.  For example, one
Head Start program we visited had rent-free space available but could
not use it because of asbestos problems.  The Head Start program
could not afford the estimated $210,000 to remove the asbestos. 

Head Start spends millions of dollars each year renovating space it
does not own.  While HHS does not collect data on the total dollar
amount spent on renovations, one HHS official estimated that Head
Start spends $20 to $30 million each year.  However, because of
short-term leases, Head Start programs have little control over
long-term use of these buildings.  According to the National Head
Start Association study on facilities, the average lease agreement is
between 1 to 3 years, and about half the Head Start programs vacated
at least one center in the past 3 years.  Once a facility is
renovated, landlords sometimes refuse to renew Head Start's lease. 
The Association estimates that Head Start spent $13 million between
1987 and 1990 to renovate buildings Head Start no longer uses. 

      DIFFICULTIES FINDING
      SUITABLE SPACE DELAY
      SERVICES AND EXPANSION
---------------------------------------------------------- Letter :5.4

The difficulties associated with finding suitable space delay
services to some children and impact future plans for expansion. 
Head Start directors we spoke with said it can take from 6 months to
2 years to locate space, causing Head Start centers to delay opening. 
One of the country's largest Head Start programs delayed opening
several new centers scheduled to serve about 3,000 children.  Centers
scheduled to open in the fall did not open until the following
spring.  According to regional HHS officials, delays result in fewer
services to children, and in some cases, parents lose interest in the
program by the time the center opens and do not enroll their
children. 

Head Start directors we interviewed were also concerned that finding
classroom space will become more difficult and may impede future
expansion plans as Head Start moves toward expanding services to more
children.  In 1992, the HHS Inspector General reported that nearly
all programs, in a random sample of 80 programs, believed that
locating adequate facilities will be the biggest challenge facing
their programs during expansion.\23

--------------------
\23 Head Start Expansion:  Grantee Experiences, p.  7. 

      EFFORTS TO OVERCOME
      DIFFICULTIES LOCATING SPACE
---------------------------------------------------------- Letter :5.5

According to survey results, Head Start programs that located space
coordinated efforts with other resources in the community.  Several
programs negotiated with local schools for classroom space or school
buildings no longer in use.  Directors of programs we visited also
told us that coordinating efforts with other community resources
helped locate space.  For example, several directors we interviewed
said that the Department of Housing and Urban Development was a good
resource to coordinate efforts with because of their experience with
space in high-poverty areas.  Several directors we spoke with
negotiated with the Department of Defense for use of vacant buildings
on closed military bases. 

In addition, the Congress passed legislation in 1992 to help Head
Start programs overcome difficulties in finding space.  The Head
Start Improvement Act allows Head Start programs to purchase existing
facilities.  However, our survey showed that less than 25 percent of
the programs even attempted to purchase space during school year
1992-93.  Head Start directors told us they did not want the
liability or the long-term maintenance required with owning a
building.  In 1994, the Congress passed legislation allowing Head
Start programs to build new facilities, but it is too early to
determine what impact this legislation will have. 

      HHS ACTIONS TO ADDRESS
      FACILITY PROBLEMS CITED BY
      HEAD START DIRECTORS
---------------------------------------------------------- Letter :5.6

HHS officials agreed that local programs often face difficulties in
locating usable space.  According to the HHS officials, facility
issues will be a major emphasis in fiscal year 1995.  They believe
that facility options available to programs, such as long-term
leasing without taking title to the property, purchasing, and
construction, will alleviate many difficulties.  The Department has
established a facilities work group to ensure that local programs
know about the various facility options and how to use them. 

While the HHS officials strongly support high standards and licensing
requirements, they are often frustrated by the inspection process for
licensing.  They stated in many cases that the delays occur due to a
lack of staff at the local and state agencies responsible for
inspecting and licensing facilities. 

   HEAD START DIRECTORS REPORTED
   QUALITY IMPROVEMENT FUNDS USED
   PRIMARILY TO IMPROVE SALARIES
   AND BENEFITS
------------------------------------------------------------ Letter :6

According to our survey results, nearly all Head Start programs
received Quality Improvements Funds during school year 1992-93. 
These funds were used primarily to improve the salaries and benefits
of Head Start staff.  On average, programs spent 58 percent on either
salary increases or fringe benefits (41 percent for increasing staff
salaries and 17 percent on improving or providing new fringe
benefits).  In addition, programs spent on average 16.7 percent on
hiring new staff, 7.9 percent on purchasing equipment, 4.4 percent on
renovating space, 2 percent on providing transportation, 2.6 percent
on training, and 8.4 percent on other purposes.  (See fig.  4.)

   Figure 4:  How Programs Used
   Quality Improvement Funds
   During School Year 1992-93

   (See figure in printed
   edition.)

Head Start directors maintained that Quality Improvement Funds are
important for improving program quality.  For example, they indicated
that Quality Improvement Funds help them attract and retain more
qualified staff, increase staff morale, provide more services to
children, and improve the quality of classroom facilities.  Directors
said they hope Quality Improvement Funds will continue, and many
believe these funds should be increased. 

HHS officials told us that, in addition to Quality Improvement Funds,
programs received $344 million in discretionary funds in fiscal year
1994 to improve program quality.  While the Department did not have
specific information on the impact of these funds, they believed the
funds helped local programs reduce turnover by increasing salaries
and adding new staff and upgrade facilities by purchasing classroom
and playground equipment. 

---------------------------------------------------------- Letter :6.1

We conducted our work between February 1993 and September 1994 in
accordance with generally accepted government auditing standards,
except we did not obtain written agency comments on this report. 
However, we did discuss a draft of this report with HHS officials. 
They generally agreed with our findings. 

As arranged with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution
until 30 days after its issue date.  At that time, we will send
copies of this report to the Secretary of Health and Human Services
and other interested parties.  Should you have any questions or wish
to discuss the information provided, please call me at (202)
512-7014.  Other GAO contacts and staff acknowledgments are listed in
appendix V. 

Sincerely yours,

Linda G.  Morra
Director, Education and
 Employment Issues

HEAD START ENROLLMENT AND FUNDING
FISCAL YEAR 1989-1995
=========================================================== Appendix I

                                                         (in
                                                        mill
                                                        ions
Year                                                       )
------------------------------------------------  ----  ----
1989                                              450,  $1,2
                                                   970    35

1990                                              540,  $1,5
                                                   930    52

1991                                              583,  $1,9
                                                   471    52

1992                                              621,  $2,2
                                                   078    02

1993                                              713,  $2,7
                                                   903    76

1994                                              740,  $3,3
                                                   300    26

1995                                              NA\a  $3,5
                                                          34
------------------------------------------------------------
\a Not applicable. 

GAO'S SURVEY METHODOLOGY
========================================================== Appendix II

   QUESTIONNAIRE DEVELOPMENT AND
   PRETESTING
-------------------------------------------------------- Appendix II:1

We designed a questionnaire to obtain information about the barriers
Head Start programs faced during the 1992-93 school year.  We
discussed development of the questionnaire with several Head Start
directors, regional Health and Human Services staff, and
representatives from the National Head Start Association.  In
addition, some of these individuals reviewed drafts of our survey. 

Before mailing our questionnaire, we conducted eight pretests--three
in California, four in Michigan, and one in Washington,
D.C.--involving Head Start directors from 14 different programs. 
These directors represented programs from a range of sizes,
geographic locations, and administrative structures.  Using the
pretest results, we revised the questionnaire to try to ensure that
(1) respondents would easily be able to answer the questions and (2)
all questions were relevant, clear, and free from bias. 

   SAMPLE DESIGN
-------------------------------------------------------- Appendix II:2

Using the 1992-93 Program Information Report (PIR), a database of
self-reported information for all Head Start grantees and delegates
nationwide, we identified 1,898 directly operated Head Start
programs.  Because our goal was to receive enough responses to
analyze the results by various types of programs, we chose a
stratified, random sampling design.  On the basis of information in
the PIR, we stratified the 1,898 programs by type of administrative
structure.\24 We developed weights for estimation based on the ratio
of the sample to the universe in each stratum.  After drawing random
samples from each stratum, we had a total of 870 programs for our
survey. 

In February 1994, we mailed the questionnaire to the 870 grantees and
delegates in our sample.  To encourage participation and increase
response rates, we mailed a second copy of the questionnaire to all
nonrespondents in early April and a third copy in early June. 

--------------------
\24 The types of administrative agencies are (1) community action
agencies, (2) school districts, (3) public and private nonprofit
organizations, (4) government agencies, and (5) Indian tribes. 

   SAMPLE ADJUSTMENT AND RESPONSE
   RATE
-------------------------------------------------------- Appendix II:3

From the 870 questionnaires we mailed, we received 654 valid
responses.  Based on returned questionnaires, we adjusted our sample
size to 855 to exclude 15 grantees that delegated management of all
of their centers and did not directly manage any portion of their
program.  The 654 valid responses resulted in an overall response
rate of 76 percent. 

   VERIFICATION OF SURVEY DATA
-------------------------------------------------------- Appendix II:4

While we did not verify the information obtained through the survey,
we did the following to reasonably ensure that the information
gathered through our survey accurately described the programs. 

We reviewed relevant literature on Head Start and early childhood
education to supplement the data collected in our survey.  (See app. 
IV for a bibliography of related literature.)

We contacted or visited Head Start programs in 18 states and
interviewed officials from the Department of Health and Human
Services in 9 of the 10 federal regions.  We judgmentally selected
the sites to reflect differences in program size, geographic
location, and type of administrative agency.  (See app.  V for a list
of sites we contacted or visited.)

We also discussed our work with representatives from the National
Head Start Association. 

   SAMPLING ERRORS
-------------------------------------------------------- Appendix II:5

Statistical sampling allows us to draw conclusions about a population
on the basis of information from a randomly selected sample of that
population.  The data used in this report are estimates, therefore,
based on a sample of Head Start programs.  Each estimate has a
measure of uncertainty, or sampling error, associated with it because
only a portion of the universe was selected for analysis. 

The size of the sampling error reflects the precision of the
estimate; the smaller the sampling error, the more precise the
estimate.  Sampling errors for the estimates in this report were
calculated at the 95-percent confidence level.  This means that the
chances are about 19 out of 20 that the actual percentage (or number)
being estimated falls within the range defined by the estimate plus
or minus the sampling error.  For example, if we estimated that 30
percent of the Head Start programs had a particular characteristic
and the sampling error for that estimate were 4 percentage points,
there would be a 95-percent chance that the actual percentage is
between 26 and 34.  Unless otherwise noted, sampling errors for the
estimates in this report do not exceed +/- 6.3 percentage points. 

SURVEY INSTRUMENT
========================================================= Appendix III

In this section, we present our survey instrument and a summary of
the responses.  Each question includes the weighted summary
statistics and the unweighted actual number of respondents that
answered each question.  In each case, we use the format we believe
best represents the data, including frequencies, medians, means, and
ranges. 

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

(See figure in printed edition.)

SITES CONTACTED OR VISITED
========================================================== Appendix IV

   HHS REGIONAL OFFICES
-------------------------------------------------------- Appendix IV:1

Region I - Boston, Mass.
Region II - New York, N.Y.
Region IV - Atlanta, Ga.
Region V - Chicago, Ill.
Region VI - Dallas, Tex.
Region VII - Kansas City, Mo.
Region VIII - Denver, Colo.
Region IX - San Francisco, Calif.
Region X - Seattle, Wash. 

   HEAD START PROGRAMS
-------------------------------------------------------- Appendix IV:2

      REGION I
------------------------------------------------------ Appendix IV:2.1

Center Inc.  - Cambridge, Mass.
Citizens for Citizens, Inc.  - Fall River, Mass.
Holyoke/Chicopee Head Start, Inc.  - Holyoke, Mass.
Community Teamwork, Inc.  - Lowell, Mass.
Community Action Program Belknap-Merrimack Counties - Concord, N.H.
C.H.I.L.D., Inc.  - Warwick, R.I. 

      REGION II
------------------------------------------------------ Appendix IV:2.2

East Orange Child Development Corporation - East Orange, N.J.
Leaguers Inc.  - Newark, N.J.
Westchester Community Opportunity - Elmsford, N.Y.
Washington County Head Start - Hudson Falls, N.Y.
Chautaqua Opportunities Inc.  - Jamestown, N.Y.
Bloomingdale Family Program, Inc.  - New York, N.Y.
Council for Preschool Children - Rio Piedras, P.R.
Municipality of Bayamon - Bayamon, P.R. 

      REGION IV
------------------------------------------------------ Appendix IV:2.3

Randolph County Board of Education - Cuthbert, Ga.
Dekalb County Economic Opportunity Authority - Decatur, Ga.
Southwest Georgia Community Action Council - Moultrie, Ga.
Concerted Services, Inc.  - Waycross, Ga. 

      REGION V
------------------------------------------------------ Appendix IV:2.4

Chicago Department of Human Services - Chicago, Ill.
Macomb County Community Services Agency - Clinton Twp., Mich.
Saginaw County Child Development Centers Inc.  - Saginaw, Mich.
Wayne County Regional Education Service Agency - Wayne, Mich.
Wayne/Westland School District - Westland, Mich.
Washtenaw County Community Services - Ypsilanti, Mich. 

      REGION VI
------------------------------------------------------ Appendix IV:2.5

Child Development, Inc.  - Russellville, Ark.
Regina Coeli Child Development Center - Covington, La.
Dona County Head Start - Las Cruces, N.  Mex.
Day Care Assoc.  of Fort Worth/Tarrant Counties - Fort Worth, Tex.
Parent and Child, Inc.  - San Antonio, Tex.
Terrell Independent School District - Terrell, Tex.
Economic Opportunity Advancement Corporation - Waco, Tex. 

      REGION VII
------------------------------------------------------ Appendix IV:2.6

Mid-Iowa Community Action, Inc.  - Marshalltown, Iowa
Northeast Kansas CAP - Hiawatha, Kans.
Economic Opportunity Foundation, Inc.  - Kansas City, Kans.
Missouri Valley Human Resource Development - Marshall, Mo.
Hall County Human Resources - Grand Island, Nebr. 

      REGION IX
------------------------------------------------------ Appendix IV:2.7

Neighborhood House Association - San Diego, Calif.
Long Beach Unified School District - Signal Hill, Calif.

      REGION XII - MIGRANT
      PROGRAMS
------------------------------------------------------ Appendix IV:2.8

East Coast Migrant Project - Arlington, Va. 

GAO CONTACTS AND STAFF
ACKNOWLEDGMENTS
=========================================================== Appendix V

   GAO CONTACTS
--------------------------------------------------------- Appendix V:1

Robert Rogers, Assistant Director, (313) 256-8011

   ACKNOWLEDGMENTS
--------------------------------------------------------- Appendix V:2

The following team members also contributed to this report:  Karen
Barry, Donna Bright Howard, John Leahy, and Laura Miner-Kowalski,
Evaluators; Joel Grossman, Clarita Mrena, and Mark Vinkenes, Survey
Design Specialists; and Kathy Ward, Technical Specialist. 

BIBLIOGRAPHY
============================================================ Chapter 0

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