Results-Oriented Management: Agency Crosscutting Actions and Plans in Drug Control, Family Poverty, Financial Institution Regulation, and Public Health Systems
Released: 2002-12-20T00:00:00

Letter

Background

Our work has repeatedly shown that mission fragmentation and program overlap are widespread in the federal government. In 1998 and 1999, we found that this situation existed in 12 federal mission areas, ranging from agriculture to natural resources and environment. We also identified, in 1998 and 1999, 8 new areas of program overlap, including 50 programs for the homeless that were administered by 8 federal agencies. These programs provided services for the homeless that appeared to be similar. For example, 23 programs operated by 4 agencies offered housing services, and 26 programs administered by 6 agencies offered food and nutrition services. Although our work indicates that the potential for inefficiency and waste exists, it also shows areas where the intentional participation by multiple agencies may be a reasonable response to a complex public problem. In either situation, implementation of federal crosscutting programs is often characterized by numerous individual agency efforts that are implemented with little apparent regard for the presence of efforts of related activities.

In our past work, we have offered several possible approaches for better managing crosscutting programs—such as improved coordination, integration, and consolidation—to ensure that crosscutting goals are consistent; program efforts are mutually reinforcing; and, where appropriate, common or complementary performance measures are used as a basis for management. One of our oft-cited proposals is to consolidate the fragmented federal system to ensure the safety and quality of food.

Perhaps most important, however, we have stated that the Results Act could provide the Office of Management and Budget (OMB), agencies, and Congress with a structured framework for addressing crosscutting program efforts. OMB, for example, could use the governmentwide performance plan, which is a key component of this framework, to integrate expected agency-level performance. It could also be used to more clearly relate and address the contributions of alternative federal strategies. Agencies, in turn, could use the annual performance planning cycle and subsequent annual performance reports to highlight crosscutting program efforts and to provide evidence of the coordination of those efforts.

OMB guidance to agencies on the Results Act states that, at a minimum, an agency’s annual plan should identify those programs or activities that are being undertaken with other agencies to achieve a common purpose or objective, that is, interagency and cross-cutting programs. This identification need cover only programs and activities that represent a significant agency effort. An agency should also review the fiscal year 2003 performance plans of other agencies participating with it in a crosscutting program or activity to ensure that related performance goals and indicators for a crosscutting program are consistent and harmonious. As appropriate, agencies should modify performance goals to bring about greater synergy and interagency support in achieving mutual goals.

In April 2002, as part of its spring budget planning guidance to agencies for preparing the President’s fiscal year 2004 budget request, OMB stated that it is working to develop uniform evaluation metrics, or “common measures” for programs with similar goals. OMB asked agencies to work with OMB staff to develop evaluation metrics for several major crosscutting, governmentwide functions as part of their September budget submissions. According to OMB, such measures can help raise important questions and help inform decisions about how to direct funding and how to improve performance in specific programs. OMB’s common measures initiative initially focused on the following crosscutting program areas: job training and employment, health.

We recently reported that one of the purposes of the Reports Consolidation Act of 2000 is to improve the quality of agency financial and performance data. We found that only 5 of the 24 CFO Act agencies’ fiscal year 2000 performance reports included assessments of the completeness and reliability of their performance data in their transmittal letters. The other 19 agencies discussed, at least to some degree, the quality of their performance data elsewhere in their performance reports.

Scope and Methodology

To address these objectives, we first defined the scope of each crosscutting program area as follows: Drug control focuses on major federal efforts to control the supply of illegal drugs through interdiction and seizure, eradication, and arrests.

Family poverty focuses on major federal efforts to address the needs of families in poverty through programs aimed at enhancing family independence and well-being. We focused on agencies that provide key support and transition tools associated with the income, health, and food support and assistance to poor families.

Financial institution regulation focuses on major federal efforts to supervise and regulate depository institutions. Supervision involves monitoring, inspecting, and examining depository institutions to assess their condition and their compliance with relevant laws and regulations. Regulation of depository institutions involves making and issuing specific regulations and guidelines governing the structure and conduct of banking.

Public health systems focuses on major federal efforts to prevent and control infectious diseases within the United States.

To identify the agencies involved in each area we relied on our previous work and confirmed the agencies involved by reviewing the fiscal year 2001 Results Act performance report and fiscal year 2003 Results Act performance plans for each agency identified as contributing to the crosscutting program area. To address the remaining objectives, we reviewed the fiscal year 2001 performance reports and fiscal year 2003 performance plans and used criteria contained in the Reports Consolidation Act of 2000 and OMB guidance. The act requires that an agency’s performance report include a transmittal letter from the agency head containing, in addition to any other content, an assessment of the completeness and reliability of the performance and financial data used in the report. It also requires that the assessment describe any material inadequacies in the completeness and reliability of the data and the actions the agency can take and is taking to resolve such inadequacies.

OMB guidance states that agency annual plans should include a description of how the agency intends to verify and validate the measured values of actual performance. The means used should be sufficiently credible and specific to support the general accuracy and reliability of the performance information that is recorded, collected, and reported.

We did not include any changes or modifications the agencies may have made to the reports or plans after they were issued, except in cases in which agency comments provided information from a published update to a report or plan. Furthermore, because of the scope and timing of this review, information on the progress agencies may have made in addressing their management challenges during fiscal year 2002 was not yet available.

We did not independently verify or assess the information we obtained from agency performance reports and plans. Also, that an agency chose not to discuss its efforts to coordinate in these crosscutting areas in its performance reports or plans does not necessarily mean that the agency is not coordinating with the appropriate agencies.

We conducted our review from September through November 2002, in accordance with generally accepted government auditing standards.

Agencies Involved in Crosscutting Areas Show Opportunities for Coordination

As shown in table 1, multiple agencies are involved in each of the crosscutting program areas we reviewed.

The discussion of the crosscutting areas below summarizes detailed information contained in the tables that appear in appendixes I through IV.

Drug Control

Fourteen million Americans use illegal drugs regularly, and drug-related illness, death, and crime cost the nation approximately $110 billion annually. From 1990 through 1997, there were more than 100,000 drug- induced deaths in the United States. Despite U.S. and Colombian efforts, the illegal narcotics threat from Colombia continues to grow and become more complex. From 1995 through 1999, coca cultivation and cocaine production in Colombia more than doubled and Colombia became a major supplier of the heroin consumed in the United States. Moreover, over time, the drug threat has become more difficult to address. ONDCP was established by the Anti-Drug Abuse Act of 1988 to set policies, priorities, and objectives for the nation's drug control program. The Director of ONDCP is charged with producing the National Drug Control Strategy, which directs the nation's antidrug efforts and establishes a budget and guidelines for cooperation among federal, state, and local entities. ONDCP’s 2001 Annual Report discussed two strategic goals that pertain to controlling the supply of drugs that enter the United States, including (1) “shielding U.S. borders from the drug threat” and (2) “reducing the supply of illegal drugs.” ONDCP reported two performance goals under the strategic goals—reduce the rate of illicit drug flow through transit zones and reduce the shipment rate of illicit drugs from arrival zones and supply zones.

For fiscal year 2001, all the agencies we reviewed—Justice, State, Transportation, and Treasury—discussed coordination with other agencies in the area of drug control, although the level of detail varied. For example, Transportation stated that the Coast Guard worked with ONDCP and Customs to finalize an interagency study of the deterrent effect that interdiction has on drug trafficking organizations. Also, Justice reported that it collaborated with Transportation to prosecute cases that relate to maritime drug smuggling. In contrast, State identified the lead and partner agencies it coordinated with to accomplish its goals, but it did not discuss specific coordination efforts. None of the agencies distinguished between coordination efforts that occurred in fiscal year 2001 and those that were planned for fiscal year 2003.

None of the agencies reported having met all of their goals and measures relating to drug control in fiscal year 2001. Customs reported that it met eight of its nine measures for seizures of cocaine, marijuana, and heroin. Customs reported that it did not meet its target for number of marijuana seizures. State reported that it met the targets for its goal of increasing foreign governments’ effectiveness in dissolving major drug trafficking organizations and prosecuting and convicting major traffickers. For the other goal—increasing foreign governments’ effectiveness in reducing the cultivation of coca, opium poppy, and marijuana—State did not meet two of its four targets. For its two measures, Transportation reported that it did not establish a target for one, the amount of drugs that are seized or destroyed at sea, and it did not meet its target for the other, the seizure rate for cocaine that is shipped through the transit zone. Justice reported that it exceeded the target for one measure—number of priority drug trafficking organizations dismantled or disrupted by the Drug Enforcement Administration (DEA)—and did not meet one of two targets for the second measure—the number of drug trafficking organizations dismantled by the Federal Bureau of Investigation (FBI).

The four agencies we reviewed—Justice, State, Transportation, and Treasury—provided explanations for not meeting their fiscal year 2001 goals that appeared reasonable. For example, Customs which is under Treasury stated that although it did not meet its target for the number of marijuana seizures, it seized more pounds of marijuana in fiscal year 2001 than in any other year. Customs stated that it believes that the number of seizures dropped because of an overall increase in sizes of marijuana loads. Furthermore, it stated that the heightened state of alert on the border following the events of September 11, 2001, might have deterred the entrance into the country of hundreds of smaller, personal-sized loads. However, none of the agencies discussed strategies for achieving the unmet goals and measures in the future.

According to their fiscal year 2003 performance plans, the agencies we reviewed expected to make progress on goals similar to those established for fiscal year 2001. All of Treasury’s performance targets were adjusted to reflect higher anticipated levels of performance. Justice and State reflected a mixture of higher and lower anticipated levels of performance. Although its goals remained the same, Transportation had measures that differed from those reported in fiscal year 2001. Justice and Transportation provided strategies that appear reasonably linked to achieving their goals for fiscal year 2003. For the goal of reducing the supply and use of drugs in the United States, Justice stated that the nine Organized Crime Drug Enforcement Task Force (OCDETF) teams would coordinate to develop a national priority target list of the most significant drug and money laundering organizations. As drug organizations are dismantled and more organizations are identified, the OCDETF teams will monitor their progress and modify the target list. To achieve its target for the amount of drugs seized or destroyed at sea—Transportation stated that the Coast Guard will (1) operate along maritime routes to deter attempts to smuggle drugs and (2) finalize an interagency study that focuses on the deterrent impact that interdiction has on drug trafficking organizations. Customs did not discuss any strategies for achieving its fiscal year 2003 goals. State provided only general statements about how it planned to achieve its fiscal year 2003 goals.

Justice, Transportation, and Treasury each commented on the overall quality and reliability of its data. For example, in its combined report and plan, Justice states that to ensure that data contained in this document are reliable, each reporting component was surveyed to ensure that the data reported met the OMB standard for data reliability. Data that did not meet this standard were not included in the report and plan. These agencies also discussed the quality of specific performance data in their fiscal year 2001 performance reports to various degrees. In its fiscal year 2001 performance report, Justice provided a discussion of data verification and validation for each performance measure. For example, for the measure of drug trafficking organizations dismantled by the FBI, an FBI field manager reviewed and approved data that were entered into the system and the data were verified through the FBI’s inspection process. Transportation reported that it used data entry software to ensure data quality and consistency by employing selection lists and logic checks. Also, Transportation stated that internal analysis and review of published data by external parties helps identify errors. Furthermore, Customs reported on the completeness, reliability, and credibility of its performance data by discussing how it verifies the data for each performance measure. State did not report on the completeness, reliability, and credibility of its performance data.

While Justice, Transportation, and Treasury acknowledged shortcomings in their performance data, they did not report steps to resolve or minimize these shortcomings. Justice reported one shortcoming which was the need to improve its reporting system for one measure—number of priority drug trafficking organizations dismantled or disrupted by DEA. Transportation stated that although data verification and validation occurs several times in the data reporting process, a potential limitation to the accuracy of its data could stem from data duplication and coding errors. Customs reported that while its data could be considered reliable, the data could be subject to input errors or duplicative reporting not identified by reviewers. State did not report on shortcomings in its performance data.

Family Poverty

Federal government agencies have major programs aimed at supporting families classified as poor. For example, HHS’s Temporary Assistance for Needy Families (TANF) program makes $16.8 billion in federal funds available to states each year. While TANF delegates wide discretion to the states to design and implement the program, it does specify four broad program goals that focus on children and families: providing assistance to needy families so that children may be cared for in their own homes or in the homes of relatives; ending the dependence of needy parents on government benefits by promoting job preparation, work, and marriage; preventing and reducing the incidence of out-of-wedlock pregnancies; encouraging the formation and maintenance of two-parent families.

In addition, Agriculture’s Food Stamp Program helps low-income individuals and families obtain a more nutritious diet by supplementing their incomes with food stamp benefits. Agriculture’s Food and Nutrition Service and the states jointly implement the Food Stamp Program, which provided about $15 billion in benefits to over 17 million low-income individuals in the United States during fiscal year 2000. In 1998, Congress passed the Workforce Investment Act (WIA) to consolidate services of many employment and training programs, mandating that states and localities use a centralized service delivery structure—the one-stop center system—to provide most federally funded employment and training assistance. We previously reported that several challenges, including program differences between TANF and WIA and different information systems used by welfare and workforce agencies, inhibit state and local coordination efforts. For example, different program definitions, such as what constitutes work, as well as complex reporting requirements under TANF and WIA hamper state and local coordination efforts. Though some states and localities have found creative ways to work around these issues, the differences remain barriers to coordination for many others. For example, antiquated welfare and workforce information systems are often not equipped to share data with each other, and as a result, sometimes one- stop center staff members have to enter the same client data into two separate systems. Although HHS and Labor have each provided some assistance to the states on how to coordinate services, available guidance has not specifically addressed the challenges that many continue to face. Moreover, HHS and Labor have not addressed differences in program definitions and reporting requirements under TANF and WIA. To address the obstacles to coordination, we recommended that HHS and Labor work together to develop ways to jointly disseminate information on how some states and localities have taken advantage of the flexibility afforded to them under TANF and WIA to pursue coordination strategies to address some of these obstacles to coordination. We also recommended that HHS and Labor, either individually or jointly, promote research that would examine the role of coordinated service delivery on outcomes of TANF clients.

The agencies we reviewed generally discussed in their performance reports and plans their efforts to coordinate with other federal agencies on programs that address family poverty. Three major interagency task forces bring all of the agencies we reviewed, plus others, together to coordinate on such programs: (1) the Interagency Council on the Homeless, which includes such federal entities as HUD, HHS, Agriculture, Commerce, Education, Energy, Justice, Labor, Defense, Transportation, Veterans Affairs, the Social Security Administration, the Federal Emergency Management Agency, the General Services Administration, and the U.S. Postal Service, (2) OMB’s Workforce Investment Act Committee, which includes HUD, Labor, HHS, and Education, to address the nation’s employment issues, and (3) the Workforce Excellence Network, which comprises Education, HHS, and Labor, conducts two major national conferences each year, in which Labor is able to “showcase” its best WIA programs. In addition, three of the five agencies we reviewed identified individual coordination efforts outside these task forces and specified the programs on which they coordinated. For example, HHS’s ACF reported that it works with Labor in Welfare-to-Work (WtW) and WIA efforts, Transportation in their Access to Jobs program, Education in providing education and training services, and HUD in providing housing assistance. Agriculture and HHS’s CMS stated that they coordinated with other agencies, but did not specify the agencies or the types of coordination efforts.

The agencies we reviewed reported varied progress in achieving their fiscal year 2001 goals and measures. For example, CMS reported meeting two goals, partially meeting one goal, and not meeting a fourth goal related to family poverty. For its goal of promoting self-sufficiency and asset development, HUD reported meeting the targets for seven of its performance indicators, missing or expecting to miss six targets, not having enough data for one target, and establishing baselines for 4 of its 18 performance indicators. Incomplete data prevented Agriculture, ACF, and HUD from reporting on all of their measures. For example, ACF was unable to report on its progress for 18 of its 23 performance indicators related to three of its goals linked to family poverty due to the time lag in receiving and validating data from states, localities, and other program partners. However, ACF was able to report that it fell short in achieving its targets for the 5 performance indicators related to two of its goals: improving the quality of child care and the Head Start Health Status program.

All of the agencies provided explanations that appeared reasonable for not meeting their goals. For example, ACF reported that two factors contributed to its failure to meet two of the three targets for its goal of improving Head Start Health Status: (1) a high student turnover rate hindered the students’ receipt of health care despite Head Start’s medical referrals and (2) Medicaid’s inability to cover dental and mental health treatment for Head Start students prevented them from receiving proper care. In addition, these agencies generally provided strategies that appeared reasonably linked to achieving the unmet goals in the future. For example, Labor outlined strategies to address its two unmet goals relating to higher wages for and retention of WtW participants in the workforce and increasing the number of child care apprenticeship programs and apprentices. Specifically, Labor proposed making retention of WtW participants more attractive by increasing grantees’ use of tax credits and continuing the Pathways to Advancement pilot project, which subsidizes employers, upgrades and advances current TANF “alumni,” and validates data at the program level, among other strategies.

For their fiscal year 2003 plan, the agencies we reviewed generally set goals similar to those established for fiscal year 2001, but increased the targets to reflect anticipated higher levels of performance. The exception to this consistency was HUD, which reported that the draft of its updated strategic plan for fiscal years 2000 through 2006 affected the fiscal year 2003 performance plan framework. The new framework introduced eight strategic goals, two of which addressed family poverty. Objectives included helping families in public and assisted housing make progress toward self-sufficiency and become homeowners, ending chronic homelessness in 10 years, and helping homeless individuals and families move to permanent housing. Four of the five agencies we reviewed— Agriculture, ACF, HUD, and Labor—provided reasonable strategies for achieving at least one of their fiscal year 2003 goals related to family poverty. For example, Labor lists departmentwide means and strategies for meeting all of its goals, most of which are to continue or improve preexisting efforts. Following the list, Labor describes eight significant new or enhanced efforts in fiscal year 2003. For its goal of having states develop a baseline and methodology for measuring the immunization of 2- year-old children under Medicaid, CMS discusses time frames for the development of each state’s baseline measure and reporting methodology, but it does not describe specific strategies for how it intends to achieve its targets for this area.

All of the agencies we reviewed addressed data quality issues in some form, although the degree to which such issues were addressed varied. Three of the five agencies—Agriculture, HUD, and Labor—included a broad statement at the beginning or end of their reports or plans stating that the reported data were generally reliable. Because all of the agencies we reviewed rely on data from the states and other grantees to report on performance for at least one of their goals, they reported on the difficulty of obtaining quality data in a timely manner. However, all of the agencies reported that they have methods for reviewing the performance data for consistency and completeness. For example, CMS stated that it had built- in quality assurance checks, technical consultants, and a review of data by CMS personnel. In addition, the agencies generally acknowledged shortcomings in the data and discussed steps they were taking to resolve or minimize the shortcomings. For example, HUD reported that it is discontinuing or updating the 18 performance indicators we reviewed in its fiscal year 2001 report because of its inability to address data reliability issues and because the connection between the indicators and the outcome measure was unknown, among other reasons. For the estimated data, HUD stated that accurate numbers would be reported in its fiscal year 2002 performance report if adjustments were necessary.

Financial Institution Regulation

Financial regulation of depository institutions in the United States is a highly complex system. Federal responsibilities for regulation and supervision are assigned to five federal regulators: FDIC, the Board of Governors of the Federal Reserve System, NCUA, OCC, and OTS. FDIC is the primary federal regulator and supervisor for federally insured state- chartered banks that are not members of the Federal Reserve System and for state savings banks whose deposits are federally insured. The Board is the federal regulator and supervisor for bank-holding companies and is the primary federal regulator for state-chartered banks that are members of the Federal Reserve System. OCC is the primary regulator of federally chartered banks or national banks. OTS is the primary regulator of all federal and state-chartered thrifts whose deposits are federally insured and their holding companies. NCUA is the primary federal regulator for credit unions.

A primary objective of federal depository institution regulators is to ensure the safe and sound practices and operations of individual depository institutions through regulation and supervision. Regulation of depository institutions involves making and issuing specific regulations and guidelines governing the structure and conduct of banking. Supervision involves the monitoring, inspecting, and examining of depository institutions to assess their condition and their compliance with relevant laws and regulations. Each federal depository regulator is responsible for its respective institutions; for example, the Board examines and regulates state member banks and OCC examines and regulates national banks.

Although the Board, FDIC, OCC, OTS, and NCUA are responsible for specific depository institutions, all of the agencies have similar oversight responsibilities for developing and implementing regulations, conducting examinations and off-site monitoring, and taking enforcement actions for those institutions that are under their respective purview. To ensure that depository institutions are receiving consistent treatment in examinations, enforcement actions, and regulatory decisions, coordination among the regulators is essential. In 1979, Congress established the Federal Financial Institutions Examination Council (FFIEC) to promote uniformity in the supervision of depository institutions by the Board, FDIC, NCUA, OCC, and OTS. It is a formal interagency body empowered to prescribe uniform principles, standards, and report forms for the federal examination of financial institutions and to make recommendations to promote uniformity in the supervision of financial institutions.

Generally, the performance reports and plans of the federal depository institutions regulators discussed possible coordination on crosscutting goals. The performance reports and plans of FDIC, OCC, and OTS described the types of coordination that they conduct with the other regulators. The Board’s 2002-2003 plan includes a section on interagency coordination of crosscutting issues. For instance, the section of the plan entitled, “Interagency Coordination of Crosscutting Issues” stated that the Board formally coordinates with other federal depository institutions regulators through the FFIEC and its participation with the Results Act Financial Institutions Regulatory Working Group, a coordinating committee of the depository institution regulators to address and report on issues of mutual concern. The performance report and plan of NCUA did not include any discussion of coordination efforts with the other federal depository institution regulators.

In 2001 and 2002, the federal depository institution regulators jointly issued guidance or regulations on a number of occasions. For example, the regulators often jointly issue guidance in areas such as the risks of brokered and other rate-sensitive deposits, temporary balance sheet growth, clarification on the accounting and reporting for loans held for sale, and consumer privacy. In addition, earlier this year, the federal depository institution regulators jointly issued proposed regulations to implement section 326 of the USA Patriot Act on customer identification. In 2001, they jointly issued guidelines on safeguarding confidential customer information.

On the basis of their fiscal year 2001 performance reports, all the federal depository institution regulators reported they made progress in achieving their fiscal year 2001 goals for the supervision and regulation function. The Board, FDIC, and OCC each reported meeting all of their goals except for one related to the examinations of depository institutions that were due for a safety and soundness examination in 2001. However, each of the three agencies provided a reasonable explanation for not achieving the goal. FDIC was unable to examine 11 banks that were scheduled for an examination for the following reasons: some institutions merged or converted their charters, some institutions moved into or changed their capital categories requiring a change in examination intervals, and one institution converted its information system. The Board did not meet its goal because it failed to complete 17 bank examinations, as required by statute and on the basis of their financial condition in 2001, but the Board provided an appropriate reason for the delay—scheduling problems with state bank regulatory agencies. The Board reported that it is implementing a new scheduling system that will partially resolve these problems. NCUA reported it generally met its performance goals, although out of its four strategic goals, it missed one out of five outcome goals for two and was unable to report on most of the outcome goals for another. OTS reported meeting all of its goals.

On the basis of their fiscal year 2003 performance plans, three of the five federal depository institution regulators designed strategies to achieve their performance goals that appear to be reasonable. Similar to the fiscal year 2001 performance reports, the performance goals focused on the scheduling of examinations under specific time frames, enforcement actions, and reviewing compliance with consumer protection statutes relating to consumer financial transactions. The Board’s performance plan outlined strategies that appeared reasonably linked to achieving its goals and objectives for promoting a safe, sound, competitive, and accessible banking system. For example, the Board’s plan proposed focusing on the areas of highest risk, promoting sound risk management practices, understanding and accommodating the effects of financial innovation and technology, improving international banking and supervisory practices, and refining and strengthening the foreign bank organizations program, among other strategies. The FDIC performance plan included a strategy for achieving its planned performance goals that also appeared reasonable. For example, FDIC plans to analyze examination-related data collected in the System of Uniform Reporting of Compliance and Community Reinvestment Act (CRA) Examination to determine whether it achieved targeted performance levels during the reporting period. In its performance plan, OCC discussed strategies for each of its strategic goals. OTS discussed general strategies, which were not clearly linked to particular performance goals.

Of the five regulators, only the performance reports of OCC and OTS commented on the completeness, reliability, and credibility of the data for the supervision and regulation function. OCC’s performance report for fiscal year 2001 concluded the data were accurate for some of the performance measurements used in the report. In its fiscal year 2001 performance report, OTS concluded that the data for its performance measures met standards for accuracy and auditability. The performance reports issued by the Board, FDIC, and NCUA did not discuss whether the performance data for the supervision and regulation areas used in the reports were complete, reliable, and credible. None of their performance reports commented on the potential shortcomings of these data.

Public Health Systems

Broadly speaking, federal involvement in the area of public health systems encompasses a mix of efforts to maintain the health of a diverse population, such as directly providing health services, regulating prescription drugs, or paying for medical services provided to the aged and the needy. In this report, we focused one aspect of the public health system—federal efforts to prevent and control infectious diseases within the United States. The spread of infectious diseases is a public health problem once thought to be largely under control. However, outbreaks over the last decade illustrate that infectious diseases remain a serious public health threat. For example, foodborne disease in the United States annually causes an estimated 76 million illnesses, 325,000 hospitalizations, and about 5,000 deaths, according to the Centers for Disease Control and Prevention (CDC). The resurgence of some infectious diseases is particularly alarming because previously effective forms of control are breaking down. For example, some pathogens (disease-causing organisms) have become resistant to antibiotics used to bring them under control or have developed strains that no longer respond to the antibiotics. The need for concerted efforts to prevent such diseases is critical to reducing this threat to the public. We have previously reported on various aspects of protecting public health, such as ensuring the vaccination of children through the Vaccines for Children program and limitations in several of CDC’s foodborne disease surveillance systems.

Agriculture and each of the five components of HHS we reviewed—CDC, CMS, FDA, HRSA, and NIH—discussed in their performance reports and performance plans coordination efforts with other agencies related to preventing infectious diseases. For example, CDC reported that it coordinated with (1) Agriculture and FDA on its food safety programs, (2) HRSA, CMS, FDA, and NIH, among others, on its immunization objectives, and (3) NIH and FDA on the development of new diagnostic and treatment tools and better vaccines for tuberculosis. Also, Agriculture reported that it coordinated with HHS and the Environmental Protection Agency regarding the goal to protect the public health by reducing the incidence of foodborne illnesses. However, none of the agencies discussed specific details about the coordination.

According to its combined fiscal year 2001 performance report and fiscal year 2003 performance plan, NIH was the only agency that reported achieving its public health systems goal—to develop new or improved approaches for preventing or delaying the onset or progression of disease and disability. Agriculture, FDA, and CDC each reported missing some of its performance targets. In addition, CDC, CMS, and HRSA lacked data to report on some or all of their performance goals for fiscal year 2001. For example, HRSA indicated that the performance data for its goal—increase the proportion of the national AIDS education and training center (AETC) interventions provided to minority health care providers—will not be collected until February 2003. Three agencies—CDC, FDA, and Agriculture—provided explanations for not meeting a measure or goal that appeared reasonable. For example, FDA reported that it missed its target—inspect 90 percent of high-risk domestic food establishments each year—because the agency purposefully diverted resources for these inspections to focus on the even greater threat of bovine spongiform encephalopathy that was breaking out in Europe at the time. None of these agencies discussed strategies to achieve the unmet goals in the future.

For fiscal year 2003, HHS’s CDC, CMS, FDA, and HRSA, and Agriculture, reported they expect to make progress on goals that were generally the same as those they reported on in fiscal year 2001. NIH developed two new subgoals for its goal of developing new or improved approaches to preventing or delaying the onset or progression of disease and disability, but did not indicate targets for the new goals. CDC developed a new goal of conducting research to identify and assess community-based prevention interventions. HRSA plans to drop one of its goals—“increase the number of minority health care and social service providers who receive training in AETCs”—because measuring the percentage of training interventions provided to minority health providers was determined to be a more accurate and appropriate method to measure the program’s progress in training health care providers. CMS and HRSA reported that they expected to achieve higher levels of performance for all of their targets. CDC, FDA, and Agriculture planned for a mixture of higher and lower levels of performance in fiscal year 2003.

Agriculture and three of the five HHS components we reviewed discussed strategies that appeared reasonably linked to achieving their fiscal year 2003 goals. For example, Agriculture reported that its performance goal— create a coordinated national and international food safety risk management system to ensure safety of U.S. meat and poultry—has a set of specifically outlined strategies to follow in order to accomplish the goal, including (1) develop national performance standards for ready-to-eat meat and poultry items, (2) ensure food safety requirements are followed by monitoring slaughter and process plants, and (3) increase reviews of foreign inspection systems to ensure the safety of imported meat, poultry, and egg products. In contrast, NIH and HRSA did not discuss strategies for achieving their fiscal year 2003 goals.

Agriculture and NIH commented on the overall quality and reliability of the performance data in their fiscal year 2001 performance reports. For example, NIH progress toward meetings its goals was assessed by its GPRA Assessment Working Group, which reviewed the performance data. In addition, CDC, CMS, and Agriculture discussed aspects of data quality for each of their performance measures. For example, CDC’s combined report and plan addresses data verification and validation for each data source corresponding to each goal. FDA and HRSA discussed narrow aspects of data quality for certain measures.

FDA and HRSA acknowledged shortcomings in their performance data and reported steps to resolve or minimize those shortcomings. For example, FDA stated that existing public health data systems are not adequate to provide accurate and comprehensive baseline data needed to draw direct relationships between FDA’s regulatory activities and changes in the number and types of foodborne illnesses that occur annually in the United States. Therefore, through coordination with CDC and Agriculture, FDA reported developing an improved food safety surveillance program called FoodNet. HRSA reported limitations related to its HIV/AIDS data collection efforts. For example, the reporting system that holds the data contains duplicate data about individuals that prevents accurate conclusions from being made. To minimize the limitations, HRSA reported it allows grantees the option of participating in a client-level reporting system. CDC and CMS acknowledged shortcomings in their data but did not discuss steps to minimize the shortcomings. NIH and Agriculture did not discuss any limitations to their performance data in the area of public health systems.

Concluding Observations

We have previously stated that the Results Act could provide OMB, agencies, and Congress with a structured framework for addressing crosscutting program efforts. In its guidance, OMB clearly encourages agencies to use their performance plans as a tool to communicate and coordinate with other agencies on programs being undertaken for common purposes to ensure that related performance goals and indicators are consistent and harmonious. We have also stated that the Results Act could also be used as a vehicle to more clearly relate and address the contributions of alternative federal strategies. The President’s common measures initiative, by developing metrics that can be used to compare the performance of different agencies contributing to common objectives, appears to be a step in this direction.

Some of the agencies we reviewed appear to be using their performance reports and plans as a vehicle to assist in collaborating and coordinating program areas that are crosscutting in nature. Those that provided more detailed information on the nature of their coordination provided greater confidence that they are working in concert with other agencies to achieve common objectives. Other agencies do not appear to be using their plans and reports to the extent they could to describe their coordination efforts to Congress, citizens, and other agencies.

Furthermore the quality of the performance information reported—how agencies explain unmet goals and discuss strategies for achieving performance goals in the future, and overall descriptions of the completeness, reliability, and credibility of the performance information reported—varied considerably. Although we found a number of agencies that provided detailed information about how they verify and validate individual measures, only 5 of the 10 agencies we reviewed for all the crosscutting areas commented on the overall quality and reliability of the data in their performance reports consistent with the requirements of the Reports Consolidation Act. Without such statements, performance information lacks the credibility needed to provide transparency of government operations so that Congress, program managers, and other decision makers can use the information.

Agency Comments and Our Evaluation

We sent drafts of this report to the respective agencies for comments. We received comments from Agriculture, the Board, FDIC, HHS, HUD, Labor, and Treasury, including OCC and OTS. The agencies generally agreed with our findings. The comments we received were mostly technical and we have incorporated them where appropriate.

Regarding drug control, Justice, through its Office of Legal Policy, commented that, as of November 2002, Justice had formalized increased cooperation with ONDCP on drug policy and operations.

Regarding public health systems, the NIH component of HHS commented that the prevention goal GAO looked at is one of five goals that together that give a comprehensive picture of the performance of NIH’s research program. Furthermore, NIH commented that there are many formal and informal ways in which it coordinates its work in the prevention arena that are not reflected in its performance plan. For example, NIH cites the Next- Generation Smallpox Vaccine Initiative, an intradepartmental task force consisting of representatives from the Office of Public Health Policy, CDC, FDA, and NIH. We acknowledge this limitation in the scope and methodology section of the report.

Regarding family poverty, HUD commented that, although GAO’s review focused on two of HUD’s eight goals, it believes all of its goals and many of its indicators have an impact on family poverty. We do not dispute HUD’s assertion that many of its goal address family poverty broadly. However, we focused on the goals that appeared to be most directly related to the scope we defined in our scope and methodology section.

Regarding financial institution regulation, FDIC commented that a lack of specific reference in the performance report regarding the completeness, reliability and credibility of the data should not lead to a negative inference.

We are sending copies of this report to the President, the Director of the Office of Management and Budget, the congressional leadership, other Members of Congress, and the heads of major departments and agencies. In addition, the report will be available at no charge on the GAO Web site at http:// www.gao.gov.

If you have any questions about this report, please contact me or Elizabeth Curda on (202) 512-6806 or daltonp@gao.gov. Major contributors to this report are listed in appendix V.

GAO Contact and Staff Acknowledgments

GAO Contact

Acknowledgments

In addition to the individual named above, the following individuals made significant contributions to this report: Steven J. Berke, Lisa M. Brown, Amy M. Choi, Peter J. Del Toro, Nancy M. Eibeck, and Debra L. Johnson.

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