Chapter 2: Title V at the National and State Levels
This chapter offers basic information about managing the Maternal and Child Health Block Grant, such as the strategic planning process of the Title V application, accountability, performance measures, budgets and helpful tips from Title V leaders who have "been there, done that."
An Important Tool for Building State Systems
While more accountability was introduced with the 1989 amendments, the Title V statute today continues to offer significant flexibility to build programs to meet your state's specific needs and to fit with your state's size, systems and cultures. This chapter provides more specific information on the federal and state components of Title V and how they work together.
As a senior manager with responsibility for Title V, it is important that you review the Title V legislation, as well as the current application and report guidance (see Chapter 6 for highlights). All of the requirements for state programs are contained in these documents; there are no regulations specific to Title V. As with every law, there are nuances and aspects that are open to interpretation. In addition to reading the tips included in this guide, talk to your counterparts in other states to learn from their experience. Federal MCH administrators can advise you within the context of the law, the guidance and federal policies.
How are State Systems Organized
Given the flexibility of Title V, there is great variation among MCH programs across the country. One (mostly) common denominator is that programs by law must be administered by the "state health agency." The exception to this rule is that a small number of CSHCN programs are located in other state agencies, usually universities, because the Title V legislation "grandfathered" existing programs.
Even with this common location there is great variety in the structure and hierarchy for state Title V programs. State executive branch agencies vary widely across the country, and their structure and responsibilities can change, especially with new administrations.
As the nation and states experienced great political shifts starting in the mid 1990s, a trend toward major reorganizations and consolidations occurred. The implications of these reorganizations on Title V and public health programs remain unclear. In larger agencies, some Title V programs, such as in Illinois and Michigan, underwent major restructuring, while others retained most of their previous structure and functions.
Today, MCH leaders usually work within larger public health agencies that include traditional areas such as epidemiology and health statistics, chronic disease prevention, and health promotion. The agency also may include environmental health, substance abuse prevention and treatment, mental health, developmental disabilities, health facilities management or regulation, and Medicaid. Whether Title V operates within or outside of the same agency, these programs can make a big difference in the ease of communication and coordination of efforts.
The units with direct responsibility for Title V programs may be called MCH, CSHCN or similar terms or may have a broader scope in family or community health. A fairly common structure is a bureau of family health (aka "big MCH") overseeing MCH preventive and primary services for women or pregnant women, children and youth (aka "little MCH"), as well as CSHCN. Related programs may be administered under or alongside these units. A 1999 AMCHP survey found that over two-thirds of state health agencies had a "family health" organizational unit, and over half of these states considered that to be the Title V unit. MCH or family health agencies commonly administer family planning programs and the supplemental food program for Women, Infants and Children (WIC). MCH or CSHCN may administer the federal early intervention program (Part C) or Medicaid waivers for home- and community-based services. Related state-funded programs, foundation initiatives and CDC programs - such as lead poisoning prevention, breast and cervical cancer screening, birth defects and developmental disabilities prevention - also often fall under the Title V unit's purview.
In some states, the scope of Title V programs may be even broader, reaching to adult-oriented programs, primary care or chronic disease prevention. States with broad units often organize, plan and link the programs in a lifespan framework. This approach can assure specific attention to children's and youths' needs, while maximizing opportunities for prevention and intervention at appropriate points across the lifespan.
Although the trend toward major, multi-agency restructuring may have accelerated recently, reorganization is a constant in public agencies, and something for which you should be prepared. While there is not one model for organizational structure and placement, some things to consider include:
- The agency's mission should support Title V's emphases on prevention, population-based and comprehensive approaches, special needs, and systems development.
- Children, youth and women, especially those with special health needs, each have unique needs that should be explicitly addressed in organizational structure.
- The agency must be competent in data collection and analysis for needs assessment, planning and evaluation, as well as program development for target populations
MCH leaders agree that it is critical for all states to have a division responsible for assuring the health of women, children, youth and families.
As with organizational structures, there is considerable variation in the education and experience of your colleagues across the country. MCH programs historically have promoted multidisciplinary teams, at the management as well as the local service level. Previous federal requirements for physicians to lead state programs were eliminated, but many states retain physicians on their senior leadership teams. These doctors, most commonly pediatricians, bring critical expertise, along with an ability to forge relationships with state physician groups that may be more difficult for non-physicians. Nurses, social workers and nutritionists also are commonly found in senior leadership positions. Clinical backgrounds are helpful in policy and program development and evaluation and offer a value often sought after by other agencies. Many clinicians in leadership positions have advanced degrees in public health or other relevant fields. With the growth of MCHB training programs, increasing numbers of Title V leaders have earned graduate deg