Detailed Information on the
Women, Infants, and Children (WIC) Assessment

Implement changes to the food package to reflect current nutritional guidelines, promote breastfeeding, and better address the health risks facing WIC population, including childhood obesity

Monitor State food package costs and cost containment efforts to promote continued cost efficiencies.

Promote efforts to address childhood obesity by supporting special State projects which will build on previously-developed WIC-specific obesity prevention interventions.

Measure: Quality of diets among low-income people, measured as the Healthy Eating Index score for people under 130% of the Federal Poverty Level (FPL)

Explanation:The Healthy Eating Index (HEI) measures people's conformance with the recommendations of the Dietary Guidelines for Americans and the Food Guide Pyramid. Each person's HEI, scaled from 0-100, represents a combination of 10 scores ranging from 0-10, corresponding to 10 specific components of a person's diet and with an increasing score based on consistency of that person's diet with the DGA/FGP. USDA uses the HEI score for low-income people, measured through data from nationally-representative nutrition and health examiniation surveys to track the overall outcomes to which WIC and othe nutrition assistance programs are intended to contribute.

Measure: Percent of postpartum WIC mothers initiating breastfeeding

Explanation:Data for this measure is drawn from WIC administrative records and reported biennially. Breastfeeding is widely acknowledged to be the most complete form of nutrition for infants, with a range of benefits for infants' health, growth, immunity and development. In general, the American Academy of Pediatrics considers breastfeeding to be the ideal method of feeding and nurturing infants.

Measure: Percent of WIC births at low birthweight

Explanation:Data for this measure is drawn from WIC administrative records and reported biennially. Low birthweight is associated with long-term disabilities such as cerebral palsy, autism, mental retardation, and other developmental disabilities. Rates of low birthweight among WIC participants have been and remain greater than those for the US population generally, reflecting the fact that the program is limited to low-income people, and designed to target individuals at nutritional risk for poor pregnancy outcomes.

Measure: Prevalence of anemia among WIC children

Explanation:Data for this measure is drawn from WIC administrative records and reported biennially. Anemia increases the risk of delays in mental and motor development in infants and young children, and is associated with comparatively poor scores in tests of intelligence, school achievement, and some cognitive processes among preschool-age and school-age children. The prevalence of anemia among US children in the US population generally is significantly lower than in among WIC children. This reflects the fact that the program targets individuals at nutritional risk. Anemia is ths most frequently cited nutrition risk among participants in all categories. Anemia has declined dramatically since 1980; this decline is principally attributed to participation in WIC.

Measure: Changes in national average WIC food package cost versus projected Thrifty Food Plan (TFP) inflation rate

Explanation:From 1996-2005, the average annual increase in the TFP was 2.75 percent. The program has targeted annual increases for the WIC food package at a maximum of 2.5 percent.

Measure: Percentage of WIC state agencies that have completed local agency training on Value Enhanced Nutrition Assessment (VENA) procedures.

Explanation:Represents adoption of new nutrition risk assessment procedures designed to better target nutrition services to client needs, improving effectiveness in addressing nutrition-related health and pregnancy outcomes.

Measure: Percentage of children, ages 2 to 4 years, receiving WIC services who are overweight or at risk of overweight

Explanation:CDC and the American Academy of Pediatrics recommend the use of BMI to screen for overweight in children beginning at 2 years old. Weight status categories based on BMI for age percentiles were developed as a result of expert committee recommendations. These categories are: underweight (less than the 5th percentile); healthy weight (5th percentile up to the 85th percentile); at risk of overweight (85th to less than the 95th percentile); and overweight (equal to or greater than the 95th percentile. (Drawn from WIC administrative data; reported biennially.) Trend data shows that rates of childhood overweight and risk of overweight have risen notably in recent years. Though the targets for reduction in this rate among WIC children is relatively modest, they represent an ambitious effort to reverse this trend.

Measure: Portion of the value of infant formula distributed through WIC that is saved as a result of rebate contracts

Explanation:Measure calculated on average infant formula rebate for milk-based formula (both liquid concentrate and powder) weighted by the total number of WIC infant participants in each State. The target of 90% set for 2008 and 2009 reflects the changing nature of the WIC infant formula marketplace. With increasing differentiation of formula types, and the use of enhanced formulas, USDA expects that it will be difficult for State agencies to secure contracts with the high level of rebates prevalent in the past. This target sets an ambitious objective to maintain a high level of rebates given these circumstances.

Measure: Percent of WIC infants who breastfed at least 6 months

Explanation:Percent of breastfed infants who were at least 6 months old at date of visit during the calendar year who had breastfed at least 6 months. (Drawn from CDC's Pediatric Nutrition Surveillance System Reports) Data is not nationally representative but in 2004 40 States contributed to the PedNSS and the majority of records (86%) are from the WIC Program. Breastfeeding is widely acknowledged to be the most complete form of nutrition for infants, with a range of benefits for infants' health, growth, immunity and development. In general, the American Academy of Pediatrics (AAP) considers breastfeeding to be the ideal method of feeding and nurturing infants. Longer duration of breastfeeding in the first year tends to confer more of the health and development benefits of breastfeeding than shorter durations. AAP and the U.S. Surgeon General recommend exclusive breastfeeding for approximately the first six months.

Is the program purpose clear?

Explanation: The Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the WIC Program - safeguards the health of low-income women, infants, & children up to age 5 who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care and social services. The scope of the Program, as stated in authorizing legislation, was based on the findings that substantial numbers of pregnant, postpartum and breastfeeding women, infants and young children from families with inadequate income are at special risk with respect to their physical and mental health by reason of inadequate nutrition or health care, or both. The purpose of the Program is to provide supplemental foods and nutrition education through payment of cash grants to State agencies that administer the Program through local agencies at no cost to eligible persons. The Program serves as an adjunct to good health care during critical times of growth and development, in order to prevent the occurrence of health problems, including drug and other harmful substance abuse, and to improve the health status of participants.

Evidence: Section 17 of the Child Nutrition Act of 1966; WIC Regulations at 7 CFR Part 246.

Does the program address a specific and existing problem, interest, or need?

Explanation: A number of studies have identified a significant, positive relationship between low socio-economic status and low birth weight, as well as between low socio-economic status and pre-term birth (Parker, et al.; Kramer; Wilcox et al). Infants born at very low birth weight are at highest risk for poor health outcomes. Many risk factors for poor birth and health outcomes among women, infants, and children are related to nutrition. (For an explanation of nutrition risks, and citations for research that supports their use, see IOM, chapters 4-6, especially pp. 70-124, 128-148, 154-249, and 253-293). These risks are in turn related to poverty (see IOM, pp. 43-47.) The WIC Program addresses this need by improving the nutrition status of low-income, nutritionally at-risk women during pregnancy, postpartum period, and while breastfeeding, as well as infants and children in the first five years of life. WIC also promotes improvements in the nutrition and health of low-income children. While 2000 brought the lowest childhood poverty rate since 1978, childhood poverty continues to exceed that of adults by 71 percent and the elderly by 58 percent. Poverty affects living conditions and access to health care and nutrition, all of which contribute to health status. The program is well positioned to address the problem of childhood overweight, a precursor to overweight and obesity later in life that is particularly prevalent among low-income children.

Evidence: Parker JD, Schoendorf KC & Kiely JL (1994): Associations between measures of socioeconomic status and low birth weight, small for gestational age, and premature delivery in the United States. Annals of Epidemiology. 44, 271-278. Kramer MS (1987): Determinants of low birth weight: methodological assessment and meta-analysis. Bulletin of the World Health Organization 65, 663-737. Wilcox MA, Smith SJ, Johnson IR, Maynard PV & Chilvers CE (1995): The effect of social deprivation on birthweight, excluding physiological and pathological effects. British Journal of Obstetrics and Gynecology. 102, 918-924. Kogan MD (1995): Social causes of low birth weight. Journal of the Royal Society of Medicine 88, 611-615. Institute of Medicine, WIC Nutrition Risk Criteria: A Scientific Assessment. Washington, DC: National Academy Press, 1996. (http://fermat.nap.edu/ catalog/5071.html.) "Women's Health USA 2005" and "Child Health USA 2005," U. S. Department of Health and Human Services, Health Resources and Services Administration.

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The WIC program is designed to provide food and nutrition services to support good pregnancy, birth, and early childhood health outcomes. Rather than duplicate other, related health care and support services, it provides referrals to those services. WIC is administered by the Federal government through State Health Departments, which operate the program through local agencies and clinics. This structure both prevents duplication of effort and fosters referrals and coordination of services. WIC nutrition benefits are not duplicative of the broad-based nutrition assistance for low-income households provided by the Food Stamp Program. Food stamps provide resources that can be used for almost any food prepared and consumed at home, and eligibility is based primarily on income and resource requirements. In contrast, WIC benefits and services are provided to a targeted population, based on income and specific nutritional risks, and the food benefits are meant to be supplemental, tailored for the participants, rather than providing for all the nutrition needs for a household. Similarly, the Child Nutrition Programs are designed to provide nutritious meals that support the well-being and educational achievement of children in schools and child care settings. To the limited extent that WIC benefits are provided to CN-eligible children, they supplement their diets with foods target to their specific needs, which the CN programs generally do not. Though WIC is in some ways duplicative of the benefits provided to the "WIC-like" participants in the Commodity Supplemental Food Program, law and regulations prevent simultaneous participation in both programs so that redundancy of effort is avoided.

Evidence: On WIC, see Section 17 of the Child Nutrition Act of 1966; WIC Regulations at 7 CFR Part 246. On Food Stamps, see Declaration of policy, Food Stamp Act of 1977 (as amended), Section 2. On Child Nutrition Programs, see the Richard B. Russell National School Lunch Act of 1946 (as amended) and the Child Nutrition Act of 1996 (as amended). On CSFP, see 7 CFR Sec. 246.7(l) and 247.7(j).

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: The WIC Program was first established as a two-year pilot program in 1972 and tested before being authorized as a permanent program in 1975. It was evaluated early in its expansion across the nation, and found to be effective in improving birth outcomes and reducing related health care costs. It is intended to provide supplemental foods containing nutrients determined by nutrition research to be lacking in the diets of pregnant, breastfeeding, and postpartum women, infants, and children. WIC nutrition education is designed to improve the health status of these individuals and achieve a positive change in dietary and physical activity habits. Nutrition education and counseling includes discussion about healthy practices for women and children, including nutrition during pregnancy, breastfeeding, smoking cessation, infant feeding practices, immunization, oral health, and the importance of physical activity to overall health. GAO inquiries have identified a number of program challenges and areas for improvement, however none represent clear evidence that alternative mechanisms or program structures could yield the same or better outcomes for reduced resource investments.

Evidence: Section 17 of the Child Nutrition Act of 1966; WIC Regulations at 7 CFR Part 246. Rush, D., W.B. Seaver, D.G. Horvitz, et al. The National WIC Evaluation: An Evaluation of the Special Supplemental Food Program for Women,Infants and Children, Volumes I-III. USDA, Food and Nutrition Service, 1986.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: WIC participants must meet residency, income, and nutritional risk requirements, as well as categorical requirements (i.e. being pregnant, postpartum, or breastfeeding woman, or a child under the age of five). WIC Program regulations define the nutritional risk assessment criteria and the prioritization of participants, to ensure that program funds are used most effectively, as well as the income eligibility guidelines, which are updated annually for the July 1-June 30 period. Erroneous WIC payments potentially can occur at the participant level (ineligible persons receive benefits) and/or the vendor level (WIC food instruments redeemed for foods not received, provided at excess prices or for unauthorized items). USDA's periodic estimates suggest a low-level of both types of errors: Certification error: The National Survey of WIC Participants (1998 data) provided estimates of certification error. Using this data in combination with more current WIC demographic information from the 2004 WIC Participant and Program Characteristics report, we estimate that about 2.5% of all WIC participants are certified in error to receive benefits. Vendor Error: The 1998 WIC Vendor Management Study developed National estimates of total vendor overcharge and undercharge, based on the prevalence of errors in three kinds of transactions in a sample of WIC vendors. It estimated that in 1998, overcharging represented 0.9 to 1.6 percent of WIC redemptions, and that undercharging represented 0.4 to 0.6 percent of redemptions. However, it is likely that the actual level of both kinds of errors is at the low end of these ranges, because in the most common type of transaction, in which a WIC client purchased all food items listed on the food instrument in the quantities and types listed, errors were less frequent. (New estimates will be completed in summer of 2006.) It should be noted that since the most recent measurements were made, FNS has taken substantial actions aimed at improving program operations and reducing improper payments, including: ?? Changing program rules so that WIC applicants now are required to document income; ?? Publishing a final rule on food-delivery systems that strengthened retail vendor management by establishing mandatory vendor selection criteria, price limitations on the amounts paid to vendors, vendor-training requirements, criteria to be used to identify high-risk vendors and such vendor-monitoring requirements as compliance investigations; and ?? Supporting the development of WIC electronic benefit transfer (EBT) systems.

Evidence: Section 17 of the Child Nutrition Act of 1966; WIC Regulations at 7 CFR Part 246. USDA Performance and Accountability Report for 2005, Appendix B (http://www.usda.gov/ ocfo/usdarpt/pdf/par11.pdf) National Survey of WIC Participants (http://www.fns.usda.gov/oane/ MENU/Published/WIC/FILES/WICSurvey.pdf) WIC Vendor Management Study (http://www.fns.usda.gov/ oane/MENU/Published/WIC/FILES/vendor.pdf)

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: WIC is one of 15 Federal nutrition assistance programs that are designed to work together to increase food security and improve diet quality for children and low-income people in the United States. USDA uses measures of the prevalence of food insecurity with hunger, and dietary quality as reflected by USDA's Healthy Eating Index, for children and low-income people, to track the overall outcomes to which nutrition assistance programs are intended to contribute. WIC's specific role, as noted in the response to Question 1.1, is to provide nutritious foods to supplement diets, information on healthy eating, and referrals to health care and social services. The proportion of eligible pregnant women and infants participating in the program is a clear, easily understood, measurable outcome of WIC operations. The relationship between this program outcome and population-wide food security and dietary quality cannot be quantified, because of the conceptual difficulty of attributing changes in these complex metrics to specific influences. However, the program's premise is that the provision of nutritious supplemental food packages tailored to the specific needs of program participants will reduce the risk of very low food security and promote good diet quality among those served, and thus tends to reduce the overall prevalence of hunger and improve diet quality among program eligibles over the long-term. USDA also tracks the initiation and duration of breastfeeding - the preferred infant feeding practice - by WIC mothers as a measure of the diet quality of participating infants. WIC also has health outcomes that it is designed to promote beyond the cross-cutting food security and diet quality outcomes shared by all nutrition assistance programs. USDA tracks the percent of WIC births at low birthweight, and the prevalence of anemia and overweight among WIC children, as three health problems related to prenatal, infant, and pediatric nutrition that WIC is intended to prevent.

Evidence: USDA Strategic Plan 2002-2007; USDA internal planning documents.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: USDA has set quantitative targets reflecting meaningful and ambitious improvements in program results for Federal nutrition assistance in the aggregate, and for WIC's long-term performance measures in particular. The targets are ambitious in that they reflect accelerated improvement, relative to recent trends, towards bringing the nutrition and health status of the at-risk populations served by WIC into parity with that of the general population. For the cross-cutting diet quality measure, changes in WIC benefits and services, including improvements in the food package and dissemination and promotion of model practices to promote healthy weight and prevent overweight among WIC children, should contribute to the targeted improvement. For the WIC-specific health measures, efforts to reach participants earlier in pregnancy, the use of improved nutrition assessments to better target services, an increased focus on and new incentives for breastfeeding, along with the overweight prevention efforts described above, are intended to achieve the targeted improvements.

Evidence: USDA Strategic Plan 2002-2007; USDA internal planning documents.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: Three of USDA's five long term outcome measures (low birthweight, and anemia and risk of overweight among children) are reported biennially on a near-census of WIC participants; these measures thus also serve in a practical sense as short-term indicators of progress toward long-term goals, though data is not available annually. A fourth measure from the same source, breastfeeding initiation, has been added as a complementary short-term measure to the long-term breastfeeding duration measure. Increases in breastfeeding initiation are an important precursor to increasing the average duration of breastfeeding among WIC participants and expanding the proportion of participants who achieve six months or more breastfeeding. In addition, USDA makes use of two annual efficiency measures: ?? Differences in the inflation rate for national average WIC food package cost relative to the food marketplace. This can be used to evaluate the program's efficiency in delivering supplemental foods at the lowest possible cost. ?? The portion of the wholesale value of infant formula distributed through WIC that is saved as a result of rebate contracts. Trends in this value track the program's ability to achieve lower costs for infant formula through its ability to achieve economies of scale in purchasing. Improvements in these measures contribute to accomplishment of WIC's long-term goals by expanding the availability of program services to eligible people within budgeted resources.

Evidence: Reports on WIC Participant and Program Characteristics (1988-2004) (http://www.fns. usda.gov/oane/MENU/Published/WIC/WIC.htm); USDA internal planning documents. .

Does the program have baselines and ambitious targets for its annual measures?

Explanation: Targets for the WIC-specific health measures are premised on the program's efforts to reach participants earlier in pregnancy, the use of improved nutrition assessments to better target services, an increased focus on and new incentives for breastfeeding, and food package and nutrition service changes to help prevent overweight, particularly among WIC children. USDA seeks increases in the national average WIC food package cost below the cost for the Thrifty Food Plan (TFP), a nutritious market basket of food that is affordable to low-income consumers, as an indicator of increased value per real program dollar spent on food. Maintaining the high proportion of the wholesale value of WIC infant formula that is rebated to the program will be challenging, in light of the increasing use of enhanced formulas and the resulting reduction in large-scale purchasing power. USDA has therefore targeted only modest improvement in this area.

Evidence: FY 2008 Explanatory Notes; USDA internal planning documents.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: The WIC Program provides funds for food benefits and nutrition and services administration to 90 State agencies. State plans, which are submitted annually by these agencies, represent their commitment to administer the WIC program according to basic regulatory requirements and goals. USDA provides State Plan guidance every year to assist WIC State agencies in preparing their State plans; this guidance represents program goals in conjunction with WIC regulations. The Department works with State agencies to make sure the annual State plans are complete and approved. USDA will use this planning process in the future to communicate new performance goals. Operational assistance funds, infrastructure grant funding, technical assistance funding and management information system funding is provided based on Agency priorities and State needs, in an effort towards meeting yearly goals set by FNS. FNS performs follow-up monitoring in the form of Advance Planning Document (APD) updates and project status reports, as well as routine expenditure monitoring.

Evidence: WIC Regulations at 7 CFR Part 246 (requirements for annual State plans).

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: FNS's annual study and evaluation agenda is designed to respond directly to the needs of program policy makers and managers to ensure that WIC and other nutrition assistance programs accomplish their missions effectively. High quality - FNS has a team of evaluation experts on staff that work with independent research firms to design and monitor data collection and analysis to ensure rigorous, high quality results. Sufficient scope - FNS frequently collects nationally-representative datasets, and uses program administrative data and nation-wide surveillance data sources, to measure performance and evaluate effectiveness. For example, biennial WIC participant characteristics reports provide nationally representative and state representative data on key performances measures including breastfeeding initiation rates, percent of WIC births at low birthweight, prevalence of anemia among WIC children, etc. Analysis of national nutrition monitoring data indicates that WIC participation is associated with increased intakes of iron, vitamin B6 and folate. CDC's analysis of the Pediatric Nutrition Surveillance System (PedNSS) revealed that WIC participation was associated with a decrease in the prevalence of anemia. Unbiased independent - FNS employs independent analysis and evaluation firms to conduct evaluations. For particularly complex or contentious issues, the agency enlists such authorities as the National Academies for independent, expert review of key program components and development of recommendations for improvement (WIC Nutrition Risk Criteria; (1996); Dietary Risk Assessment in the WIC Program (2002); Estimating Eligibility and Participation for the WIC Program (2001 and 2003); WIC Food Package (2004 and 2005)). Conducted on a regular basis to support program improvements - Large-scale evaluations are typically conducted periodically as resources permit, with more frequent examinations of particular areas of performance or operations to inform decisions on potential program changes. For example, national studies that examine WIC certification error are conducted every 10 years with the next decennial national study scheduled for 2008. Studies examining erroneous payments at the vendor level are conducted every 7-10 years with a current study underway examining FY2005 activity. It should be noted that causality cannot be established without experimental studies that include random assignment. These are unethical in the case of WIC as they would require withholding benefits from low income, at-risk mothers, infants and children at critical stages of growth and development. To this end, experimental studies have been designed so that the control group continues to receive WIC benefits and the treatment groups receives enhanced benefits. An example of such a study is the Breastfeeding Intervention Design Study, in which the control group would continue to receive existing postpartum support services offered by the WIC clinics and the treatment groups would receive peer counseling interventions.

Evidence: Study of WIC Participant and Program Characteristics (1988-2004); Oliveira, V. and C. Gundersen, WIC and the Nutrient Intake of Children (2000), USDA/ERS; The 1998 National Survey of WIC Participants; The 1998 WIC Vendor Management Study; WIC Nutrition Risk Criteria; (1996); Dietary Risk Assessment in the WIC Program (2002); Estimating Eligibility and Participation for the WIC Program (2001 and 2003); WIC Food Packages: Time for a Change (2005).

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: Program budget requests routinely estimate the effect of legislation, policy changes, and program participation trends on program costs. Budget requests are tied to the performance goals of the USDA Strategic Plan, as reflected in the Summary of Budget and Performance budget exhibit. The exhibit identifies both food benefits and State nutrition services and administration costs, and related Federal administration and oversight costs, thus making explicit the full cost of the program in the budget request.

Evidence: FNS FY 2008 budget submission. USDA Strategic Goal 5: Improve the Nation's Nutrition and Health and its related objectives: 5.1-Improved Access to Nutritious Food and 5.2-Healthier Eating Habits and Lifestyles.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: USDA updates its strategic plan every three years, consistent with the requirements of the Government Performance and Results Act, and publishes performance data annually through its Performance and Accountability Report. USDA has been working with OMB to develop annual and long-term performance measures with baselines and ambitious targets, and to integrate performance data into annual budget requests.

Evidence: USDA Strategic Plan 2002-2007 and Performance and Accountability Reports are available on the web at http://www.usda.gov/ocfo/perfmgmt/index.htm; "Demonstrating Results" document provided to OMB 10/20/2005; letter from W. Scott Steele to Robert Shea.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: WIC State agencies are required to report participation and expenditures data on a monthly basis. Data on per participant food costs, rebate savings and nutrition services and administration are analyzed to determine effectiveness of program operations. In addition, WIC vendor management data is reported on an annual basis, in The Integrity Profile (TIP), a data reporting system on WIC vendors. FNS regional offices are responsible for performing regular management evaluations, in which aspects of program management and performance are examined and corrective actions are recommended for improvement.

Evidence: WIC regulations at 7 CFR Part 246. The results and findings of Management Evaluations (MEs) are compiled in the State Technical Assistance Review Coverage Summary Report. Findings and best practices for each year's MEs are shared with Regional Offices and State agencies. Expenditures are monitored continually throughout the year to ensure that funds are used most effectively, and reallocations of funds are performed in order to adjust for shifts in participation and costs. A specific example of recent management actions: In response to Management Evaluations conducted in American Samoa which indicated abuse by a number of vendors, those vendors were eliminated from participation in the WIC Program. Because the MEs also indicated many more vendors had been approved for the Program than were necessary to serve the population, additional vendors were not approved when others were eliminated; and pending applications were not approved.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: As a fixed grant program, all WIC State agencies are required to provide WIC benefits to as many eligible participants as the grant allows while still adhering to all applicable laws and regulations. Spending standards for both food and nutrition services and administrative funds are in place, which ensure costs are appropriate for the number of participants served. If these standards are met, grants are adjusted accordingly. Through frequent management evaluations, audits and other reviews, performance against the grant and operational procedures are checked for compliance with Federal statute and regulatory requirements.

Evidence: Section 17 of the Child Nutrition Act of 1966; WIC regulations at 7 CFR Part 246

Are funds (Federal and partners') obligated in a timely manner, spent for the intended purpose and accurately reported?

Explanation: Funds are obligated by formula consistent with program regulations. Funds are obligated appropriately and consistently for their intended purpose and within a timely manner and schedule. Erroneous WIC payments potentially can occur at the participant level (ineligible persons receive benefits) and/or the vendor level (WIC food instruments redeemed for foods not received, provided at excess prices or for unauthorized items). USDA's periodic estimates suggest a low-level of both types of errors: Certification error: The National Survey of WIC Participants (1998 data) provided estimates of certification error. Using this data in combination with more current WIC demographic information from the 2004 WIC Participant and Program Characteristics report, we estimate that about 2.5% of all WIC participants are certified in error to receive benefits. Vendor Error: The 1998 WIC Vendor Management Study developed National estimates of total vendor overcharge and undercharge, based on the prevalence of errors in three kinds of transactions in a sample of WIC vendors. It estimated that in 1998, overcharging represented 0.9 to 1.6 percent of WIC redemptions, and that undercharging represented 0.4 to 0.6 percent of redemptions. However, it is likely that the actual level of both kinds of errors is at the low end of these ranges, because in the most common type of transaction, in which a WIC client purchased all food items listed on the food instrument in the quantities and types listed, errors were less frequent. (New estimates will be completed in summer of 2006.) It should be noted that since the most recent measurements were made, FNS has taken substantial actions aimed at improving program operations and reducing improper payments, including: ?? Changing program rules so that WIC applicants now are required to document income; ?? Publishing a final rule on food-delivery systems that strengthened retail vendor management by establishing mandatory vendor selection criteria, price limitations on the amounts paid to vendors, vendor-training requirements, criteria to be used to identify high-risk vendors and such vendor-monitoring requirements as compliance investigations; and ?? Supporting the development of WIC electronic benefit transfer (EBT) systems.

Evidence: SF-132, Apportionment and Reapportionment Schedule; SF-133, Report on Budget Execution and Budget Resources; and Financial Status Report (SF-269) USDA Performance and Accountability Report for 2005, Appendix B (http://www.usda.gov/ ocfo/usdarpt/pdf/par11.pdf) National Survey of WIC Participants (http://www.fns.usda.gov/oane/ MENU/Published/WIC/FILES/WICSurvey.pdf) WIC Vendor Management Study (http://www.fns.usda.gov/ oane/MENU/Published/WIC/FILES/vendor.pdf)

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: Mothers participating in WIC are encouraged to breastfeed their infants if possible, but State WIC agencies will provide infant formula to mothers who choose not to or cannot breastfeed. WIC State agencies are required by law to have competitively-bid infant formula rebate contracts with infant formula manufacturers. This means a WIC State agency agrees to provide one brand of infant formula to the majority of its participants and in return receives a rebate from the manufacturer for each can of infant formula that is purchased by WIC participants. As a result, WIC pays the lowest possible price for infant formula. The brand of infant formula provided by WIC varies from State agency to State agency, depending on which company has the rebate contract in a particular State. The WIC Program saves over $1.5 billion each year from infant formula manufacturers. This is a big savings to the WIC Program which allows many more eligible women, infants, and children to be served. In general, approximately 1 out of every 4 participants is served with the savings generated by rebates. In addition, administrative costs are kept at a minimum through oversight by FNS on state expenditures, including information technology (IT) expenditures. To help reduce system development costs and maximize efficiencies in the use of technology to operate the WIC Program, FNS has supported State consortiums to design, develop and implement three model WIC management information systems, which will then be deployed to other WIC State agencies. To ensure these projects are on time and on budget, earned value management and Federal project oversight is required.

Evidence: WIC regulations at 7 CFR Part 246

Does the program collaborate and coordinate effectively with related programs?

Explanation: The WIC Program works at the Federal, State, and local levels with various programs affecting the health of children and families, including the Centers for Disease Control (CDC), the Maternal and Child Health Program, the Center for Medicare and Medicaid Services, and the Indian Health Service at the Department of Health and Human Services, the Food Stamp Program, the National Immunization Program, the Breastfeeding Consortium, and CDC's National Breastfeeding Awareness Campaign. FNS has worked with Medicaid to develop policy encouraging WIC and Medicaid to work collaboratively at the State and local level to ensure that nutritional needs of mutual clients are met, and stating that Medicaid should be the primary payor for WIC-eligible exempt infant formulas and medical foods issued to WIC participants who are also Medicaid beneficiaries. FNS and the National Immunization Program at CDC have an ongoing cooperative effort aimed at increasing immunization rates of pre-school children participating in WIC. FNS and CDC together develop national policy and guidance on immunization promotion activities in the WIC Program; CDC provides funding to State immunization programs to help communities create networks to provide access and improve the quality of immunization service. FNS recently worked with the HHS Indian Health Service to update a memorandum of understanding promoting coordination and co-location of WIC services at Indian Health Service facilities.

Evidence: Policy Memorandum #2001-6, issued September 2001, "Medical Primary Payor for Exempt Infant Formulas and Medical Foods." December 11, 2000 - Executive Memorandum directing the Secretaries of Agriculture and Health and Human Services to focus efforts to increase immunization levels of children participating in WIC. July 2001 - WIC Immunization Action Plan, issued by FNS and the CDC National Immunization Program, containing 7 goals and 24 bench-marked objectives in coordination, data collection, training, and funding. (The goals and objectives of the strategic plan were completed in 2003.) August 2001 - FNS policy memorandum outlining standardized procedures for WIC agencies to use in screening for immunization status and referral. In 2002, training materials developed by FNS, CDC, National WIC Association, American Academy of Pediatrics, Association of Immunization Manager, Association of State and Territorial Health Officials, and the advocacy organization Every Child by Two. Materials are available on the web at www.nal.usda.gov/wicworks.

Does the program use strong financial management practices?

Explanation: Financial Management practices of the agency comply with 1) Federal financial management system requirements, 2) Federal accounting standards and 3) the Standard General Ledger at the transaction level. Financial Management practices applicable to the program are established in program regulation and OMB Circulars. Program regulations stipulate that the agency perform state and local management evaluations and review food instrument reimbursements to vendors." Federal financial management reviews assure that administrative costs are accounted for properly.

Evidence: Guidance requirements: WIC Program Act & regulations; OMB Circulars: A-87 (Cost Principles for State, Local, and Indian Tribal Governments), A-102 (Grants and Cooperative Agreements with State and Local Governments), A-123 (Management Accountability and Control), and A-136 (Financial Reporting Requirements). Reports/procedures/activities: USDA Financial Statement audits; Program management evaluations; Federal Financial management reviews.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: WIC has obtained decennial measures of certification accuracy (1988 & 1998) and as a result has changed procedures to improve certification accuracy. However, this measure does not provide a measurement of improper payments as required by IPIA. Pending approval of funding, the next decennial study will be performed during FY 2008 which will produce the required payment measurement. This measurement will be available in FY2009. A study of WIC vendors is in its final stages. The results, including a measurement of vendor improper payments, will be available by Oct 2006. FNS has taken steps in recent years to improve vendor management through regulations, including a WIC/Food Stamp Vendor Disqualification Rule, a Food Delivery Rule, and a Vendor Cost Containment Rule (interim rule).

Evidence: Program management evaluations; Federal Financial management reviews; WIC Cost Allocation Guide; OIG Audit #27099-33-SF (Administrative Costs, Oregon) -- Decennial WIC Certification Studies; WIC Vendor Studies Vendor Cost Containment Rule (interim rule), published November 29, 2005, 70 FR 71708 Final Food Delivery Rule, published December 29, 2000, 65 FR 83248 Final WIC/Food Stamp Vendor Disqualification Rule, published March 18, 1999, 64 FR 13311

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: Oversight is accomplished through regular reports from State agencies to FNS, in the form of monthly participation reports, through expenditures reports, and through annual management evaluations.

Evidence: WIC regulations at 7 CFR Part 246

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: FNS collects and publishes a range of data from States. Performance reports made available on the FNS web site include monthly State data on participation, food costs, average monthly food cost per person, and nutrition services and administrative costs, by State. Vendor management data is also available through the FNS website. In addition, studies and evaluations are made available through the web, as well as WIC Participant and Program Characteristics Report, which is published every two years.

Evidence: WIC regulations at 7 CFR Part 246. The program data is available at http://www.fns.usda.gov/pd/wichome.htm. Studies, evaluations, and Participant and Program Characteristics reports are available at http://www.fns.usda.gov/oane/MENU/Published/WIC/WIC.htm.

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: The program's historical data show that it is largely meeting its long-term performance goals. The proportion of WIC births at low birthweight and the prevalence of anemia among WIC children have declined substantially over the last decade. The proportion of WIC children who are overweight or at risk of overweight has grown in recent years, but this has occurred during a period when overweight risk has also grown substantially in this age group in the general population. The proportion of WIC mothers initiating breastfeeding has grown steadily over the last decade. The proportion of WIC mothers breastfeeding for at least six months has also increased, but more slowly. Cross-Cutting Measures: Reductions in the rate of very low food security were somewhat ahead of target through 2000. Rising unemployment and increased poverty have contributed to a increases in the rate of very low food securityin subsequent years. There was a small improvement in the HEI between 1996 and 1999-2000.

Evidence: WIC Participant Characteristics reports; USDA food security reports; analysis of National Health and Nutrition Examination Survey data (for Healthy Eating Index)..

Does the program (including program partners) achieve its annual performance goals?

Explanation: WIC consistently serves the projected number of women, infants and children targeted in its annual budget request without the need to resort to waiting lists, thus maintaining effective program access for all eligibles who wish to apply. As a discretionary program, WIC is constrained by the level of funds appropriated to support its operations, yet the program has consistently served over 70% of eligible infants, and over 60% of eligible pregnant women, over the last decade. WIC has achieved steady increases in the proportion of pregnant women enrolling in WIC during their first trimester of pregnancy. WIC has maintained a high rate of utilization (>95%) of total food grant funds spent for 5 years, underscoring the programs achievement of maximum caseload with budgeted funds. Over the last fifteen years, and in most individual years during the period, the national average WIC food package cost has increased at a rate below the general rate of food inflation.

Evidence: "WIC Program Coverage: How Many Eligible Individuals Participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): 1994 to 2003?"; USDA-FNS Explanatory Notes; WIC Participant Charavteristics reports; internal USDA program data; USDA reports on the cost of the Thrifty Food Plan.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: WIC has maintained a high rate of utilization (>95%) of total food grant funds spent for 5 years, underscoring the programs achievement of maximum caseload with budgeted funds. Over the last fifteen years, and in most individual years during the period, the national average WIC food package cost has increased at a rate below the general rate of food inflation.

Evidence: USDA-FNS Explanatory Notes; WIC Participant Characteristics reports; internal USDA program data

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: WIC is widely regarded as one of the Nation's most successful and cost-effective public health programs. WIC is highly effective in reaching the low-income pregnant, breastfeeding, postpartum women, infants, and children with almost two thirds of WIC enrollees having reported household income at or below the poverty line compared to 11 percent in the general population. WIC serves as a gateway to pre- and postnatal health care. WIC infants and children are more likely than income-eligible nonparticipants to have a regular source of health care. Studies have also shown that WIC participation has a positive impact on the likelihood that children will have up-to-date immunizations. In terms of cost containment, WIC has been very successful in obtaining significant rebates on infant formula from the retail market. WIC is widely regarded as one of the Nation's most successful and cost-effective public health programs. It was one of three programs cited by OMB in 2001 as examples of federal programs that work and warrant taxpayer investment. Its cluster of benefits??supplemental nutritious foods, nutrition counseling and education, and linkages to other important health and social services??make WIC a unique nutrition program targeted to low income pregnant, breastfeeding, and postpartum women, infants and young children. It is better targeted for its intended beneficiaries, more soundly grounded in nutrition science, and better integrated with other federal, State, and local programs than many other Federal programs. Except for the Maternal and Child Health (MCH) Block Grant, no other federal programs intended to promote perinatal and early childhood health have been rated effective by OMB (e.g., Office of Women's Health, Healthy Community Access Program, Head Start, etc). With respect to the MCH Block Grant, WIC is far more targeted on promoting healthy birth outcomes and improved childhood nutrition nationwide; State discretion in MCH-funded activities make this program less focused in this regard. Further, WIC has been the subject of more national and/or State-level research and evaluation efforts than the MCH Block Grant. There are a few privately funded programs, such as the Nurse-Family Partnership Program, that show great promise at improving health and social outcomes for WIC's target population. At present, however, this model is more intensive and expensive compared to WIC. The Nurse-Family Partnership provides intensive home visits by registered nurses at a cost of almost $10,000 a family, compared to WIC's annual average cost of around $650-$700 per participant (inclusive of administrative costs). WIC is designed to work in conjunction with such intensive programs by providing nutrition support and access to other services, in order to promote intended health outcomes.

Evidence: Fox, M. (ed.) Effects of Food Assistance and Nutrition Programs on Nutrition and Health: Volume 4, Executive Summary of the Literature Review (2004) USDA/ERS; Bartlett et al., WIC Participant and Program Characteristics: 2002, USDA/FNS; Cole, N and M. Fox, Nutrition and Health Characteristics of Low-Income Populations, Volume 2, WIC Program Participants and Nonparticipants (2004) USDA/ERS.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: The available body of research provides strong, suggestive evidence that WIC has a positive impact on mean birthweight, the incidence of low birthweight, and several other key birth outcomes, and that these positive effects lead to savings in Medicaid costs. Several studies suggest that WIC participation increases children's intakes of selected nutrients including iron, vitamin B6 and folate. There have been sustained increases in WIC coverage of pregnant women in their early stages of pregnancy with almost half of the pregnant women enrolling in WIC in the first trimester. Most applicants certified for WIC are correctly determined to be income eligible. Certification error is relatively low (4.5%) and expected to go down with new income documentation requirements. Estimates of vendor overcharges are less than 2 percent of total program payments.

Evidence: Fox, M. (ed.) Effects of Food Assistance and Nutrition Programs on Nutrition and Health: Volume 4, Executive Summary of the Literature Review (2004) USDA, ERS, pp. 12-20; Oliveira, V and C Gunderson, WIC and the Nutrient Intake of Children (2000) USDA, ERS; Bartlett et al., WIC Participant and Program Characteristics: 2002, USDA, FNS; Cole, N. et al, National Survey of WIC Participants (2001) USDA/FNS.