1
Introduction

The Title X Family Planning Program, the nation’s only federal program devoted exclusively to providing family planning services, is authorized under Title X of the Public Health Service Act (P.L. 91-572) (see Appendix B for the statute and Appendix C for the regulations). Created in 1970, Title X is devoted to the provision of comprehensive family planning and related health services—services that help women and men maintain reproductive health; avoid unintended pregnancies; and determine the number, timing, and spacing of their children—all of which contribute to the health and social and economic well-being of women, men, children, and families. This report presents the results of an independent evaluation of the Title X program performed by a committee convened by the Institute of Medicine (IOM).

OVERVIEW OF THE TITLE X PROGRAM

The Title X program provides grants to public and nonprofit private entities to assist in establishing and operating family planning clinics, training service providers, conducting research, and engaging in community-based education and outreach. The program is designed to provide access to contraceptive services, supplies, and information for all who want and need them. By law, however, priority is given to low-income individuals. Consistent with this basic goal, in 2006 the Title X program provided family planning and related reproductive health services to almost 5 million people, 67 percent of whom had incomes at or below the federal poverty level and 61 percent of whom were uninsured (RTI International, 2008).



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1 Introduction The Title X Family Planning Program, the nation’s only federal pro- gram devoted exclusively to providing family planning services, is autho- rized under Title X of the Public Health Service Act (P.L. 91-572) (see Appendix B for the statute and Appendix C for the regulations). Created in 1970, Title X is devoted to the provision of comprehensive family planning and related health services—services that help women and men maintain reproductive health; avoid unintended pregnancies; and determine the num- ber, timing, and spacing of their children—all of which contribute to the health and social and economic well-being of women, men, children, and families. This report presents the results of an independent evaluation of the Title X program performed by a committee convened by the Institute of Medicine (IOM). OVERVIEW OF THE TITLE X PROGRAM The Title X program provides grants to public and nonprofit private entities to assist in establishing and operating family planning clinics, train- ing service providers, conducting research, and engaging in community- based education and outreach. The program is designed to provide access to contraceptive services, supplies, and information for all who want and need them. By law, however, priority is given to low-income individuals. Consistent with this basic goal, in 2006 the Title X program provided family planning and related reproductive health services to almost 5 million people, 67 percent of whom had incomes at or below the federal poverty level and 61 percent of whom were uninsured (RTI International, 2008). 2

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2 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM The Office of Family Planning (OFP) administers the Title X program. OFP is located within the Office of Population Affairs (OPA), a part of the Department of Health and Human Services’ (HHS) Office of Public Health and Science. OPA is the focal point for HHS on reproductive health issues, administering the Title X program through OFP and Title XX (funds for services to pregnant and parenting adolescents) through the Office of Ado- lescent Pregnancy Programs. Although the Title X program is administered by OFP, its budget line is located within the Health Resources and Services Administration. OFP develops the program’s priorities, policies, and perfor- mance measures and oversees all Title X family planning grants. The Title X Act includes four major provisions: (1) family planning services, (2) train- ing, (3) research, and (4) information and education. At least 90 percent of appropriations must be used for family planning services. The four provi- sions are described briefly below. Further detail about the administration and management of the program is provided in Chapter 4. Family Planning Services OFP allocates Title X funds to 10 HHS Regional Offices. These offices, in turn, award funds to grantees in states and territories through a competi- tive process. Grantees may provide family planning services and/or award funds to delegates to provide services under negotiated, written agree- ments with the grantees. The Regional Offices monitor program operations through site visits; Comprehensive Program Reviews; and the collection of data for the Family Planning Annual Report (FPAR) on characteris- tics of clients served, services provided, personnel providing services, and project revenues. The Regional Offices also provide feedback to grantees on their performance and communicate with OFP regarding legal and policy issues. OFP promulgates Program Guidelines that provide grantees with an operational interpretation of the law and regulations, defining the ser- vices that must be provided by all projects funded through Title X (see Appendix D). In addition, the Program Guidelines outline other related services that may be offered, as well as requirements for equipment and supplies, medical records, and quality assurance. Services financed in whole or in part by Title X are delivered through a wide variety of community-based clinics and sites that include state and local health departments, hospitals, university health centers, Planned Parenthood affiliates, community health centers, independent clinics, and other public and nonprofit agencies. Clinics supported by Title X provide preventive health care services, such as patient education and counseling; breast and pelvic examinations; screenings for cervical cancer, sexually transmitted diseases, and HIV; pregnancy diagnosis and counseling; contra-

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25 INTRODUCTION ceptive methods and/or prescriptions for contraceptive supplies and other medications; and basic infertility services (which include an initial infertility interview, education, a physical examination, counseling, and appropriate referral). Other services provided include general physical examinations, follow-up, and referrals. Training, Research, and Information and Education The remaining 10 percent of Title X funds goes to these three areas. Training is supported for staff of family planning clinics to strengthen over- all clinic performance and patient care. Biomedical, behavioral, and health services research is aimed at improving the delivery of family planning services. Information and education includes information dissemination through a centralized clearinghouse and community-based education and outreach activities. STUDY PURPOSE AND CHARGE TO THE COMMITTEE In 2005, the Title X program participated in the Program Assess- ment Rating Tool (PART) process, which was developed and is carried out by the Office of Management and Budget (OMB) (the PART is pre- sented in Appendix E). The purpose of the PART process is to assess and improve the performance of federal programs (OMB, 2005), with particular emphasis on identifying program strengths and weaknesses to inform funding and management decisions that will make the program more effective. As a result of the Title X PART evaluation, OMB deter- mined that the program was strong in its overall purpose, design, and management but that performance goals for some program activities had not yet been developed. In addition, OMB determined that, while there had been several focused evaluations of the Title X program, none of them had been broadly based, independent, and of sufficient quality and scope. To fill this gap, OFP asked the IOM to provide an independent evaluation of the program, including an assessment of its overall impact. The IOM committee examined Title X’s administration and management, as well as the extent to which the program’s objectives and operational requirements meet the needs of its target populations. The committee also considered whether the program has adequately adapted to ongoing changes in technology, medical practice, social values and norms, and other related influences that might bear on its effectiveness. The evalua- tion encompassed the questions of how well the program is meeting its stated goals, how adequate the scope of services is for meeting the needs of low-income individuals, how well the program is managed at its vari- ous levels, and how it functions in relation to other public and private

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26 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM sources of support for family planning services. The specific charge to the committee is presented in Box 1-1. The purpose of this report is to present the committee’s assessment of the impact of the Title X program in relation to its stated goals, and to recommend ways to improve the program’s effectiveness and efficiency. The committee’s recommendations are based on scientific evidence and expert judgment. The findings and recommendations presented in this report are intended to assist OFP and OPA in administering the program to best meet its goals. Other audiences include policy makers, Title X grantees and del- egates, those who receive services through Title X, and the general public. BOX 1-1 Charge to the Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program The HHS Office of Family Planning (OFP) has requested that the Institute of Medicine provide a critical review of the Title X Family Planning Program. The review will assess the administration and management of the program including whether the program is serving its intended target populations. The committee will also consider the extent to which the Title X program needs to reexamine the scope of its services, objectives, and operational requirements of the program. Specifically, the committee will review and address the following questions: • Has OFP used the PART process (including identified goals, objectives, and justification) to reflect relevant goals, outcomes, and processes needed to successfully implement and manage the Title X program? • D oes the overall Title X program meet relevant past, existing, and foresee- able future needs of the targeted population, using accepted medical, family planning, recognized and professional standards and reproductive health practices (based on the existing legislation, regulations, and guidance)? • H ow do Title X program goals and objectives contribute to those of HHS? • T o what extent is the Title X program complementary versus duplicative of other public or private funding sources (e.g., Medicaid, community health centers)? As part of this review and assessment, the committee will consider Title X documentation including legislation, regulations, previous program evaluations (such as those conducted by the Government Accountability Office, Office of the Inspector General, and Research Triangle Institute), guidance documents (Program Review Tool, Title X guidelines, Program Instructions), data manage- ment (FPAR guidance), Service Delivery Improvement RFAs (past and present final reports), and the PART Evaluation (level of contribution to improving service delivery).

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27 INTRODUCTION STUDY APPROACH During this 24-month study, the IOM committee used several methods for data collection (see Appendix A for a full description of the study methods). The committee held five meetings and three public workshops to gather information on topics related to the study charge and to hear the views of a variety of groups and individuals knowledgeable about Title X. The committee also conducted a literature review to assess evidence on populations in need of family planning services, the services provided, the role of Title X and other funding sources in providing those services, barriers to care, and best practices. In addition, the committee received documents from OFP describing the operation of the program, previous evaluations of the program, and the program’s grantees and delegates. These documents included Title X’s authorizing legislation, relevant regu- lations, program evaluations, guidance documents, annual reports, service delivery improvement reports, and the program’s PART evaluation. The committee also commissioned two papers to obtain an in-depth assessment of the organization and management of the program and issues pertaining to measuring the quality of family planning services. Finally, the committee conducted 16 visits to Title X clinics to learn how services are provided in various settings and to gather the views of local administrators and service providers about the program, which yielded important data for the commit- tee’s deliberations (see Appendix F for a summary of the site visits). ORGANIZATION OF THE REPORT The remainder of this report is divided into four chapters. Chapter 2 provides an overview of family planning in the United States, including the importance of family planning services, key milestones, and the changing context in which the Title X program operates. Chapters 3 through 5 pro- vide the committee’s evaluation of the Title X program. Chapter 3 addresses the goals and priorities of the program and the extent to which they have been accomplished. Chapter 4 reviews the organization and management of Title X and how the program relates to other sources of funding for family planning services. Finally, Chapter 5 provides the committee’s assessment of whether data collected by OFP are adequate to monitor the program and measure its outcomes, and how the Title X evaluation system can be improved. The committee’s key findings are highlighted throughout these chapters, each of which ends with the committee’s conclusions and recom- mendations. Table 1-1 shows the chapter(s) in which each element of the study charge (Box 1-1) is addressed.

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2 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM TABLE 1-1 Elements of the Study Charge and Chapters Where They Are Addressed Chapter(s) Element of Charge The review will assess the administration and management of the program 3, 4 including whether the program is serving its intended target populations. The committee will also consider the extent to which the Title X program 3, 4, 5 needs to reexamine the scope of its services, objectives and operational requirements of the program. • Has OFP used the PART process (including identified goals, objectives, 3, 5 and justification) to reflect relevant goals, outcomes, and processes needed to successfully implement and manage the Title X program? • Does the overall Title X program meet relevant past, existing, and 3, 4 foreseeable future needs of the targeted population, using accepted medical, family planning, recognized and professional standards and reproductive health practices (based on the existing legislation, regulations, and guidance)? • How do Title X program goals and objectives contribute to those of 3 HHS? To what extent is the Title X program complementary versus duplicative of 4 other public or private funding sources (e.g., Medicaid, community health centers)?