The Health Center Program is governed by section 330 of the Public Health Service Act. By law, grantees with community health center funding must operate health center sites that serve, in whole or in part, an MUA or MUP; provide comprehensive primary care services as well as enabling services, such as translation and transportation, that facilitate access to health care; are available to all residents of the health center service area, with fees on a sliding scale based on patients’ ability to pay; are governed by a community board of which at least 51 percent of the members are patients of the health center; and meet performance and accountability requirements regarding administrative, clinical, and financial operations. HRSA may designate a geographic area—such as a group of contiguous counties, a single county, or a portion of a county—as an MUA based on the agency’s index of medical underservice, composed of a weighted sum of the area’s infant mortality rate, percentage of population below the federal poverty level, ratio of population to the number of primary care physicians, and percentage of population aged 65 and over. In previous reports, we identified problems with HRSA’s methodology for designating MUAs, including the agency’s lack of timeliness in updating its designation criteria. HRSA published a notice of proposed rule making in 1998 to revise the MUA designation system, but it was withdrawn because of a number of issues raised in over 800 public comments. In February 2008, HRSA published a revised proposal and the period for pubic comment closed in June 2008. HRSA uses a competitive process to award Health Center Program grants. There are four types of health center grants available through the Health Center Program, but only new access point grants are used to establish new health center sites. Since 2005, HRSA has evaluated applications for new access point grants using eight criteria for which an application can receive a maximum of 100 points (see table 1). Grant applications are evaluated by an objective review committee—a panel of independent experts, selected by HRSA, who have health center- related experience. The objective review committee scores the applications by awarding up to the maximum number of points allowed for each criterion and prepares summary statements that detail an application’s strengths and weaknesses in each evaluative criterion. The summary statements also contain the committee’s recommended funding amounts and advisory comments for HRSA’s internal use; for example, the committee may recommend that HRSA consider whether the applicant’s budgeted amount for physician salaries is appropriate. The committee develops a rank order list—a list of all evaluated applications in descending order by score. HRSA uses the internal comments— recommended funding amounts and advisory comments—from the summary statements and the rank order list when making final funding decisions. In addition, HRSA is required to take into account the urban/rural distribution of grants, the distribution of funds to different types of health centers, and whether a health center site is located in a sparsely populated rural area. HRSA also considers the geographic distribution of health center sites—to determine if overlap exists in the areas served by the sites—as well as the financial viability of grantees. After the funding decisions are made, HRSA officials review the summary statements for accuracy, remove the recommended funding amounts and any advisory comments, and send the summary statements to unsuccessful applicants as feedback. For fiscal year 2007, HRSA funded 60 training and TA cooperative agreements with various national, regional, and state organizations to support the Health Center Program, in part, by providing training and technical assistance to health center grant applicants. Cooperative agreements are a type of federal assistance that entails substantial involvement between the government agency—in this case, HRSA—and the funding recipient—that is, the national, regional, and state organizations. HRSA relies on these training and TA cooperative agreement recipients to identify underserved areas and populations across the country in order to assist the agency in increasing access to primary care services for underserved people. In addition, these cooperative agreement recipients serve as HRSA’s primary form of outreach to potential applicants for health center grants. For each cooperative agreement recipient, HRSA assigns a project officer who serves as a recipient’s main point of contact with the agency. The duration of a cooperative agreement, known as the project period, is generally 2 or 3 years, with each year known as a budget period. As a condition of the cooperative agreements, HRSA project officers and the organizations jointly develop work plans detailing the specific training and technical assistance activities to be conducted during each budget period. Activities targeted to new access point applicants can include assistance with assessing community needs, disseminating information in underserved communities regarding health center program requirements, and developing and writing grant applications. After cooperative agreement recipients secure funding through a competitive process, they reapply for annual funding through what is known as a noncompeting continuation application each budget period until the end of their project period. These continuation applications typically include a work plan and budget for the upcoming budget period and progress report on the organization’s current activities. HRSA policy states that cooperative agreement recipients will undergo a comprehensive on-site review by agency officials once every 3 to 5 years. During these comprehensive on-site reviews, HRSA evaluates the cooperative agreement recipients using selected performance measures— developed in collaboration with the organizations—and requires recipients to develop action plans to improve operations if necessary. The purpose of these reviews is for the agency to evaluate the overall operations of all its funding recipients and improve the performance of its programs. Almost half of MUAs nationwide lacked a health center site in 2006. The percentage of MUAs that lacked a health center site varied widely across census regions and states. We could not determine the types of primary care services provided by health center sites in MUAs because HRSA does not maintain data on the types of services offered at each site. Because of this, the extent to which individuals in MUAs have access to the full range of comprehensive primary care services provided by health center sites is unknown. Based on our analysis of HRSA data, we found that 47 percent of MUAs nationwide—1,600 of 3,421—lacked a health center site in 2006. We found wide variation among census regions—Northeast, Midwest, South, and West—and across states in the percentage of MUAs that lacked health center sites. (See fig. 1.) The Midwest census region had the most MUAs that lacked a health center site (62 percent) while the West census region had the fewest MUAs that lacked a health center site (32 percent). More than three-quarters of the MUAs in 4 states—Nebraska (91 percent), Iowa (82 percent), Minnesota (77 percent), and Montana (77 percent)— lacked a health center site; in contrast, fewer than one-quarter of the MUAs in 13 states—including Colorado (21 percent), California (20 percent), Mississippi (20 percent), and West Virginia (19 percent)— lacked a health center site. (See app. I for more detail on the percentage of MUAs in each state and the U.S. territories that lacked a health center site in 2006.) In 2006, among all MUAs, 32 percent contained more than one health center site; among MUAs with at least one health center site, 60 percent contained multiple health center sites. Almost half of all MUAs in the West census region contained more than one health center site while less than one-quarter of MUAs in the Midwest contained multiple health center sites. The states with three-quarters or more of their MUAs containing more than one health center site were Alaska, Connecticut, the District of Columbia, Hawaii, New Hampshire, and Rhode Island. In contrast, Nebraska, Iowa, and North Dakota were the states where less than 10 percent of MUAs contained multiple sites. We could not determine the types of primary care services provided at each health center site because HRSA does not collect and maintain readily available data on the types of services provided at individual health center sites. While HRSA requests information from applicants in their grant applications on the services each site provides, in order for HRSA to access and analyze individual health center site information on the services provided, HRSA would have to retrieve this information from the grant applications manually. HRSA separately collects data through the UDS from each grantee on the types of services it provides across all of its health center sites, but it does not collect data on services provided at each site. Although each grantee with community health center funding is required to provide the full range of comprehensive primary care services, it is not required to provide all services at each health center site it operates. HRSA officials told us that some sites provide limited services— such as dental or mental health services. Because HRSA lacks readily available data on the types of services provided at individual sites, it cannot determine the extent to which individuals in MUAs have access to the full range of comprehensive primary care services provided by health center sites. This lack of basic information can limit HRSA’s ability to assess the full range of primary care services available in needy areas when considering the placement of new access points and limit the agency’s ability to evaluate service area overlap in MUAs. Our analysis of new access point grants awarded in 2007 found that these awards reduced the number of MUAs that lacked a health center site by about 7 percent. Specifically, 113 fewer MUAs in 2007—or 1,487 MUAs in all—lacked a health center site when compared with the 1,600 MUAs that lacked a health center site in 2006. As a result, 43 percent of MUAs nationwide lacked a health center site in 2007. Despite the overall reduction in the percentage of MUAs nationwide that lacked health center sites in 2007, regional variation remained. The West and Midwest census regions continued to show the lowest and highest percentages of MUAs that lacked health center sites, respectively. (See fig. 2.) Three of the census regions showed a 1 or 2 percentage point change since 2006, while the South census region showed a 5 percentage point change. The minimal impact of the 2007 awards on regional variation is due, in large part, to the fact that more than two-thirds of the nationwide decline in the number of MUAs that lacked a health center site—77 out of the 113 MUAs—occurred in the South census region. (See table 2.) In contrast, only 24 of the 113 MUAs were located in the Midwest census region, even though the Midwest had nearly as many MUAs that lacked a health center site in 2006 as the South census region. Overall, while the South census region experienced a decline of 12 percent in the number of MUAs that lacked a health center site, the other census regions experienced declines of approximately 4 percent. The South census region experienced the greatest decline in the number of MUAs lacking a health center site in 2007 compared to other census regions, in large part, because it was awarded more new access point grants that year than any other region. (See table 3.) Specifically, half of all new access point awards made in 2007—from two separate new access point competitions—went to applicants from the South census region. When we examined the High Poverty County new access point competition, in which 200 counties were targeted by HRSA for new health center sites, we found that 69 percent of those awards were granted to applicants from the South census region. (See fig. 3.) The greater number of awards made to the South census region for this competition may be explained by the fact that nearly two-thirds of the 200 counties targeted were located in the South census region. (For detail on the High Poverty County new access point competition by census region and state, see app. II.) When we examined the open new access point competition, which did not target specific areas, we found that the South census region also received a greater number of awards than any other region under that competition. Specifically, the South census region was granted nearly 40 percent of awards; in contrast, the Midwest received only 17 percent of awards. (See table 4.) HRSA oversees cooperative agreement recipients, but the agency’s oversight is limited because it does not have standardized performance measures to assess the performance of the cooperative agreement recipients in assisting new access point applicants and the agency is unlikely to meet its policy timeline for conducting comprehensive on-site reviews. Although HRSA officials told us that they were developing standardized performance measures, they provided no details on the specific measures that may be implemented. Moreover, more than a third of the summary statements sent to unsuccessful applicants for new access point competitions held in fiscal years 2005 and 2007 contained unclear feedback. HRSA oversees the activities of its cooperative agreement recipients using a number of methods. HRSA officials told us that over the course of a budget period, project officers use regular telephone and electronic communications to discuss cooperative agreement recipients’ activities as specified in work plans, review the status of these activities, and help set priorities. According to HRSA officials, there is no standard protocol for these communications, and their frequency, duration, and content vary over the course of a budget period and by recipient. HRSA staff also reviews annual noncompeting continuation applications to determine whether the cooperative agreement recipients provided an update on their progress, described their activities and challenges, and developed a suitable work plan and budget for the upcoming budget period. The progress reports submitted by cooperative agreement recipients in these annual applications serve as HRSA’s primary form of documentation on the status of cooperative agreement recipients’ activities. HRSA’s oversight of training and TA cooperative agreement recipients is based on performance measures tailored to the individual organization rather than performance measures that are standardized across all recipients. Specifically, HRSA uses individualized performance measures in cooperative agreement recipients’ work plans and comprehensive on- site reviews to assess recipients’ performance. For cooperative agreement recipients’ work plans, recipients propose training and technical assistance activities in response to HRSA’s cooperative agreement application guidance, in which the agency provides general guidelines and goals for the provision of training and technical assistance to health center grant applicants. The guidance requires recipients to develop performance measures for each activity in their work plans. When we analyzed the work plans of the 8 national organizations and 10 PCAs with training and TA cooperative agreements, we found that these measures varied by cooperative agreement recipient. For example, we found that for national organizations, performance measures varied from (1) documenting that the organization’s marketing materials were sent to PCAs to (2) recording the number of specific technical assistance requests the organization received to (3) producing monthly reports for HRSA detailing information about potential applicants. For state PCAs, measures varied from (1) the PCA providing application review as requested to (2) holding specific training opportunities—such as community development or board development—to (3) identifying a specific number of applicants the PCA would assist during the budget period. Because these performance measures vary for cooperative agreement recipients’ activities, HRSA does not have comparable measures to evaluate the performance of these activities across recipients. HRSA’s oversight of cooperative agreement recipients is limited in some key respects. One limitation is that the agency does not have standardized measures for its assessment of recipients’ performance of training and technical assistance activities. Without standardized performance measures, HRSA cannot effectively assess the performance of its cooperative agreement recipients with respect to the training and technical assistance they provide to support Health Center Program goals. For example, HRSA does not require that all training and TA cooperative agreement recipients be held to a performance measure that would report the number of successful applicants each cooperative agreement recipient helped develop in underserved communities, including MUAs. Standardized performance measures could help HRSA identify how to better focus its resources to help strengthen the performance of cooperative agreement recipients. HRSA officials told us that they are developing performance measures for the agency’s cooperative agreement recipients, which they plan to implement beginning with the next competitive funding announcement, scheduled for fiscal year 2009. However, HRSA officials did not provide details on the particular measures that it will implement, so it is unclear to what extent the proposed measures will allow HRSA to assess the performance of cooperative agreement recipients in supporting Health Center Program goals through such efforts as developing successful new access point grant applicants. HRSA’s oversight is also limited because the agency’s comprehensive on- site reviews of cooperative agreement recipients do not occur as frequently as HRSA policy states. According to HRSA’s stated policy, the agency will conduct these reviews for each cooperative agreement recipient every 3 to 5 years. The reviews are intended to assess—and thereby potentially improve—the performance of the cooperative agreement recipients in supporting the overall goals of the Health Center Program. This support can include helping potential applicants apply for health center grants, identifying underserved areas and populations across the country, and helping HRSA increase access to primary care services for underserved populations. As part of the comprehensive on-site reviews, HRSA officials consult with the relevant project officer, examine the scope of the activities cooperative agreement recipients have described in their work plans and reported in their progress reports, and develop performance measures in collaboration with the recipient. Similar to the performance measures in cooperative agreement recipients’ work plans, the performance measures used during comprehensive on-site reviews are also individually tailored and vary by recipient. For example, during these reviews, some recipients are assessed using performance measures that include the number of training and technical assistance hours the recipients provided; other recipients are assessed using measures that include the number of applicants that were funded after receiving technical assistance from the recipient or the percentage of the state’s uninsured population that is served by health center sites in the Health Center Program. After an assessment, HRSA asks the recipient to develop an action plan. In these action plans, the reviewing HRSA officials may recommend additional activities to improve the performance of the specific measures they had identified during the review. For example, if the agency concludes that a cooperative agreement recipient needs to increase the percentage of the state’s uninsured population served by health center sites in the Health Center Program, it may recommend that the recipient pursue strategies to develop a statewide health professional recruitment program and identify other funding sources to improve its ability to increase access to primary care for underserved people. Although HRSA’s stated policy is to conduct on-site comprehensive reviews of cooperative agreement recipients every 3 to 5 years, HRSA is unlikely to meet this goal for its training and TA cooperative recipients that target assistance to new access point applicants. In the 4 years since HRSA implemented its policy for these reviews in 2004, the agency has evaluated only about 20 percent of cooperative agreement recipients that provide training and technical assistance to grant applicants. HRSA officials told us that they have limited resources each year with which to fund the reviews. However, without these reviews, HRSA does not have a means of obtaining comprehensive information on the performance of cooperative agreement recipients in supporting the Health Center Program, including information on ways the recipients could improve the assistance they provide to new access point applicants. More than a third of summary statements sent to unsuccessful applicants from new access point grant competitions held in fiscal years 2005 and 2007 contained unclear feedback. Based on our analysis of 69 summary statements, we found that 38 percent contained unclear feedback associated with at least one of the eight evaluative criteria, while 13 percent contained unclear feedback in more than one criterion. We defined feedback as unclear when, in regard to a particular criterion, a characteristic of the application was noted as both a strength and a weakness without a detailed explanation supporting each conclusion. We found that 26 summary statements contained unclear feedback. We found 41 distinct examples of unclear feedback in the summary statements. (See table 5.) HRSA’s stated purpose in providing summary statements to unsuccessful applicants is to improve the quality of future grant applications. However, if the feedback HRSA provides in these statements is unclear, it may undermine the usefulness of the feedback for applicants and their ability to successfully compete for new access point grants. Based on our analysis, the largest number of examples of unclear feedback was found in the need criterion, in which applications are evaluated on the description of the service area, communities, target population—including the number served, encounter information, and barriers-—and the health care environment. For example, one summary statement indicated that the application clearly demonstrated and provided a compelling case for the significant health access problems for the underserved target population. However, the summary statement also noted that the application was insufficiently detailed and brief in its description of the target population. Seven of the examples of unclear feedback were found in the response criterion, in which applications are evaluated on the applicant’s proposal to respond the target population’s need. One summary statement indicated that the application detailed a comprehensive plan for health care services to be provided directly by the applicant or through its established linkages with other providers, including a description of procedures for follow-up on referrals or services with external providers. The summary statement also indicated that the application did not provide a clear plan of health service delivery, including accountability among and between all subcontractors. Awarding new access point grants is central to HRSA’s ongoing efforts to increase access to primary health care services in MUAs. From 2006 to 2007, HRSA’s recent new access point awards achieved modest success in reducing the percentage of MUAs nationwide that lacked a health center site. However, in 2007, 43 percent of MUAs continue to lack a health center site, and the new access point awards made in 2007 had little impact on the wide variation among census regions and states in the percentage of MUAs lacking a health center site. The relatively small effect of the 2007 awards on geographic variation may be explained, in part, because the South census region received a greater number of awards than other regions, even though the South was not the region with the highest percentage of MUAs lacking a health center site in 2006. HRSA awards new access point grants to open new health center sites, thus increasing access to primary health care services for underserved populations in needy areas, including MUAs. However, HRSA’s ability to target these awards and place new health center sites in locations where they are most needed is limited because HRSA does not collect and maintain readily available information on the services provided at individual health center sites. Having readily available information on the services provided at each site is important for HRSA’s effective consideration of need when distributing federal resources for new health center sites because each health center site may not provide the full range of comprehensive primary care services. This information can also help HRSA assess any potential overlap of services provided by health center sites in MUAs. HRSA could improve the number and quality of grant applications it receives—and thereby broaden its potential pool of applicants—by better monitoring the performance of cooperative agreement recipients that assist applicants and by ensuring that the feedback unsuccessful applicants receive is clear. However, limitations in HRSA’s oversight of the training and TA cooperative agreement recipients hamper the agency’s ability to identify recipients most in need of assistance. Because HRSA does not have standardized performance measures for these recipients— either for their work plan activities or for the comprehensive on-site reviews—the agency cannot assess recipients’ performance using comparable measures and determine the extent to which they support the overall goals of the Health Center Program. One standardized performance measure that could help HRSA evaluate the success of cooperative agreement recipients that assist new access point applicants is the number of successful grant applicants each cooperative agreement recipient develops; this standardized performance measure could assist HRSA in determining where to focus its resources to strengthen the performance of cooperative agreement recipients. HRSA’s allocation of available resources has made it unlikely that it will meet its goal of conducting comprehensive on-site reviews of each cooperative agreement recipient every 3 to 5 years. Without these reviews, HRSA does not have comprehensive information on the effectiveness of training and TA cooperative agreement recipients in supporting the Health Center Program, including ways in which they could improve their efforts to help grant applicants. Given the agency’s concern regarding available resources for its comprehensive on-site reviews, developing and implementing standardized performance measures for training and TA cooperative agreement recipients could assist HRSA in determining the cost-effectiveness of its current comprehensive on-site review policy and where to focus its limited resources. HRSA could potentially improve its pool of future applicants by increasing the extent to which it provides clear feedback to unsuccessful applicants on the strengths and weaknesses of their applications. HRSA intends for these summary statements to be used by applicants to improve the quality of future grant applications. However, the unclear feedback HRSA has provided to some unsuccessful applicants in fiscal years 2005 and 2007 does not provide those applicants with clear information that could help them improve their future applications. This could limit HRSA’s ability to award new access point grants to locations where such grants are needed most. We recommend that the Administrator of HRSA take the following four actions to improve the Health Center Program: Collect and maintain readily available data on the types of services provided at each health center site to improve the agency’s ability to measure access to comprehensive primary care services in MUAs. Develop and implement standardized performance measures for training and TA cooperative recipients that assist applicants to improve HRSA’s ability to evaluate the performance of its training and TA cooperative agreements. These standardized performance measures should include a measure of the number of successful applicants a recipient assisted. Reevaluate its policy of requiring comprehensive on-site reviews of Health Center Program training and TA cooperative agreement recipients every 3 to 5 years and consider targeting its available resources at comprehensive on-site reviews for cooperative agreement recipients that would benefit most from such oversight. Identify and take appropriate action to ensure that the discussion of an applicant’s strengths and weaknesses in all summary statements is clear. In commenting on a draft of this report, HHS raised concerns regarding the scope of the report and one of our recommendations and concurred with the other three recommendations. (HHS’s comments are reprinted in app. III.) HHS also provided technical comments, which we incorporated as appropriate. HHS said its most significant concern was with our focus on MUAs and the exclusion of MUPs from the scope of our report. In our analysis, we included the health center sites of 90 percent of all Health Center Program grantees. We excluded from our review sites that were associated with the remaining 10 percent of grantees that received HRSA funding to serve specific MUPs only because they are not required to serve all residents of the service area. Given our research objective to determine the location of health center sites that provide services to residents of an MUA, we excluded these specific MUPs and informed HRSA of our focus on health center sites and MUAs. We agree with HHS’s comment that it could be beneficial to have information on the number of grants awarded to programs serving both MUAs and MUPs generally to fully assess the coverage of health center sites. HHS also commented that our methodology did not account for the proximity of potential health center sites located outside the boundary of an MUA. While we did not explicitly account for the proximity of potential health center sites located outside an MUA, we did include the entire area of all zip codes associated with an MUA. As a result, the geographic boundary of an MUA in our analysis may be larger than that defined by HRSA, so our methodology erred on the side of overestimating the number of MUAs that contained a health center site. With regard to our reporting on the percentage of MUAs that lacked a health center site, HHS stated that this indicator may be of limited utility, because not all programs serving MUAs and MUPs are comparable to each other due to differences in size, geographic location, and specific demographic characteristics. Specifically, HHS commented that our analysis presumed that the presence of one health center site was sufficient to serve an MUA. In our work, we did not examine whether MUAs were sufficiently served because this was beyond the scope of our work. Moreover, since HRSA does not maintain site-specific information on services provided and each site does not provide the same services, we could not assess whether an MUA was sufficiently served. HHS also noted that a health center site may not be the appropriate solution for some small population MUAs; however, we believe it is reasonable to expect that residents of an MUA—regardless of its size, geographic location, and specific demographic characteristics—have access to the full range of primary care services. With regard to our first recommendation that HRSA collect and maintain site-specific data on the services provided at each health center site, HHS acknowledged that site-specific information would be helpful for many purposes, but it said collecting this information would place a significant burden on grantees and raise the program’s administrative expenses. We believe that having site-specific information on services provided would help HRSA better measure access to comprehensive primary health care services in MUAs when considering the placement of new health center sites and facilitate the agency’s ability to evaluate service area overlap in MUAs. HHS concurred with our three other recommendations. With regard to our second recommendation, HHS stated that HRSA will include standardized performance measures with its fiscal year 2009 competitive application cycle for state PCAs and that HRSA plans to develop such measures for the national training and TA cooperative agreement recipients in future funding opportunities. With regard to our third recommendation, HHS commented that HRSA has developed a 5-year schedule for reviewing all state PCA grantees. HHS also stated that HRSA is examining ways to better target onsite reviews for national training and TA cooperative agreement recipients that would most benefit from such a review. Finally, HHS agreed with our fourth recommendation and stated that HRSA is continuously identifying ways to improve the review of applications. As arranged with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution of it until 30 days after its issue date. At that time, we will send copies of this report to the Secretary of HHS, the Administrator of HRSA, appropriate congressional committees, and other interested parties. We will also make copies of this report available to others upon request. In addition, the report will be available at no charge on the GAO Web site at http:///www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Staff members who made major contributions to this report are listed in appendix IV. In addition to the contact named above, Nancy Edwards, Assistant Director; Stella Chiang; Krister Friday; Karen Howard; Daniel Ries; Jessica Cobert Smith; Laurie F. Thurber; Jennifer Whitworth; Rachael Wojnowicz; and Suzanne Worth made key contributions to this report.

Summary: Health centers funded through grants under the Health Center Program--managed by the Health Resources and Services Administration (HRSA), an agency in the U.S. Department of Health and Human Services (HHS)--provide comprehensive primary care services for the medically underserved. HRSA provides funding for training and technical assistance (TA) cooperative agreement recipients to assist grant applicants. GAO was asked to examine (1) to what extent medically underserved areas (MUA) lacked health center sites in 2006 and 2007 and (2) HRSA's oversight of training and TA cooperative agreement recipients' assistance to grant applicants and its provision of written feedback provided to unsuccessful applicants. To do this, GAO obtained and analyzed HRSA data, grant applications, and the written feedback provided to unsuccessful grant applicants and interviewed HRSA officials. Grant awards for new health center sites in 2007 reduced the overall percentage of MUAs lacking a health center site from 47 percent in 2006 to 43 percent in 2007. In addition, GAO found wide geographic variation in the percentage of MUAs that lacked a health center site in both years. Most of the 2007 nationwide decline in the number of MUAs that lacked a site occurred in the South census region, in large part, because half of all awards made in 2007 for new health center sites were granted to the South census region. GAO also found that HRSA lacks readily available data on the services provided at individual health center sites. HRSA oversees training and TA cooperative agreement recipients, but its oversight is limited in key respects and it does not always provide clear feedback to unsuccessful grant applicants. HRSA oversees recipients using a number of methods, including regular communications, review of cooperative agreement applications, and comprehensive on-site reviews. However, the agency's oversight is limited because it lacks standardized performance measures to assess the performance of the cooperative agreement recipients and it is unlikely to meet its policy goal of conducting comprehensive on-site reviews of these recipients every 3 to 5 years. The lack of standardized performance measures limits HRSA's ability to effectively evaluate cooperative agreement recipients' activities that support the Health Center Program's goals with comparable measures. In addition, without timely comprehensive on-site reviews, HRSA does not have up-to-date comprehensive information on the performance of these recipients in supporting the Health Center Program. HRSA officials stated that they are in the process of developing standardized performance measures. Moreover, more than a third of the written feedback HRSA sent to unsuccessful Health Center Program grant applicants in fiscal years 2005 and 2007 contained unclear statements. The lack of clarity in this written feedback may undermine its usefulness rather than enhance the ability of applicants to successfully compete for grants in the future.