Mr. Chairman and Members of the Committee:
I am Dr. Ciro Sumaya, Administrator of the Health Resources and Services
Administration (HRSA). I am accompanied this morning by Dr. Audrey Nora,
Director of HRSA's Maternal and Child Health Bureau (MCHB) and Dr. Thurma
McCann, Director of MCHB's Division of Healthy Start. The Division of Healthy
Start provides leadership and administration of the Healthy Start Initiative.
I am pleased to have this opportunity to share with you our efforts to
reduce infant mortality in the United States through a demonstration program
called the Healthy Start Initiative. In my testimony today, I will summarize
the progress Healthy Start has made toward improving maternal and infant health
in 22 communities across the country and describe the Department's plan to
benefit from what we have learned.
Infant mortality--the death of babies before their first birthday--has been
a tragic public health problem during the past 100 years that continues to be
among the highest National priorities. It is addressed through both research
and activities that seek to reduce the numbers.
During this past century, progress has been made through public and private
studies and grant programs. Nevertheless, the United States continues to have
one of the highest infant mortality rates among industrialized nations: the
United States infant mortality rate ranks 23rd compared to other industrialized
nations, with countries such as Northern Ireland, Belgium, Japan, and
Singapore having lower infant mortality rates than we do. And there is a large
disparity between the infant mortality rates for some minority populations and
the general population. For example, the infant mortality rate of
African-Americans is more than twice that of whites.
In 1989, a White House Task Force on Infant Mortality recommended that
actions be taken to address persistently high infant mortality rates in this
Nation. A HRSA-convened Interagency Committee on Want Mortality more
specifically recommended targeting the reduction of high infant death rates
associated with ethnic and racial populations. Healthy Start emerged as a
demonstration program in 1991, with funds appropriated initially under P. L.
102-27, "The Dire Emergency Supplemental Appropriations Act for FY 1991," and
renewed in annual Labor-HHS appropriations bills ever since.
The Healthy Start program was based on the premise that new community-based
strategies were needed and should come from communities in order to attack the
causes of infant mortality and it major precursor, low birthweight, especially
among high-risk- populations. The five principles underlying Healthy Start's
strategies are: innovation; community commitment and involvement; increased
access to health care; service integration; and personal responsibility. The
program was designed as a unique attempt to pull together the working commitment
of local families, volunteers, nonprofit organizations, and private companies,
in addition to the relevant health care and social service providers.
Applicants for Healthy Start grants were sought among urban and rural
communities with infant mortality rates at least 1.5 times the national average.
In the fall of 1991, 15 applicants (13 urban and 2 rural) were awarded grants
with the goal of reducing infant mortality in their project areas by 50 percent
over a 5-year period. FY 1991 funds supported year-long comprehensive planning
activities the projects began serving clients 'in FY 1993.
Based on strong bipartisan support for Healthy Start and a firm commitment
by the Clinton Administration to reduce infant mortality, in late 1994, 7
additional communities (5 urban and 2 rural) were awarded Healthy Start Special
Projects grants. These communities had infant mortality rates as high as the
original 15 projects, and already had operational community consortia and infant
mortality reduction programs in place. The goal of these Special Project grants
is to significantly reduce infant mortality rates in their target areas over a
two-year period. Because these 7 additional communities had a stable
infrastructure and plan of action, federal funds reinforced their ability to be
more targeted in their efforts to reduce infant mortality.
The 22 current Healthy Start projects serve communities from Florida to
California, Boston to Birmingham, the Northern Plains to the Mississippi Delta.
Over the 3 operational years of FY 1993- 1995, the projects have translated the
concept of community-based service integration into a wide variety of infant
mortality reduction strategies, each tailored to address unique community needs
and to overcome barriers to care. These programs and activities have addressed
the following objectives:
To significantly reduce infant mortality and increase the number of women
receiving early prenatal care. The 1993-1994 provisional vital statistics, as
reported by the 15 original Healthy Start projects, indicate some success in
reduction of infant mortality rates across the sites, as compared to the
1984-1988 baseline, although the precise contribution of Healthy Start funding
cannot yet be measured. Many projects also recorded fewer low birthweight
infants; more women abstaining from smoking, alcohol and drugs during pregnancy;
and substantial increases in the number of women receiving adequate prenatal
To build and strengthen community-based systems of care. Healthy Start
challenges communities to actively address the medical, behavioral and
psychosocial needs of women and infants. Each project has developed a strong
coalition of local and State governments, providers, corporations and
businesses, schools, religious groups, and neighborhood organizations. These
coalitions help guide the local projects, offer resources to support programs
and provide contacts to support efforts to sustain the programs after Federal
Example: In Philadelphia, 65 community-based organizations actively
participate.in the Philadelphia Healthy Start Provider Council, which
facilitates collaboration and communication among all coalition members.
Example: In Cleveland local residents act as "Neighborhood Consortia
Builders" to motivate members of the community and area businesses to play an
active financial role in their Healthy Start project.
To increase access to and utilization of quality primary care and support
services. Healthy Start projects have enhanced service delivery systems by
integrating existing programs, including the services of State/local maternal
and child health agencies and community health centers. In many of these
communities, Healthy Start projects also expanded provider capacity with the
services of obstetricians/gynecologists, perinatologists, pediatricians,
advanced practice nurses and other professionals. Clinics' and providers'
visiting hours have been expanded. To encourage women to take advantage of
these health care and support services, each Healthy, Start project has
developed extensive outreach and case management programs.
Some projects employ and train community residents as outreach workers to
seek out pregnant women and families and oversee their experiences as Healthy
Start clients. Since these outreach workers are also residents of the target
neighborhoods, the), speak the language of the community and know first-hand how
to reach those who most need the help.
Example: Pittsburgh Healthy Start workers go to local banks on paydays to do
prenatal care registration and to Laundromats, where outreach workers have an
opportunity to talk with women.
Example: At the Northern Plains site-- which provides services to 19 Native
American tribal communities in Iowa, North Dakota, South Dakota and
Nebraska--case managers help women through pregnancy, childbirth and the
challenge of new parenthood. me program has yielded fewer pre-term births;
increased involvement by males and other community members; and increased
To create enabling services and coordinate existing programs that overcome
barriers to health care. Healthy Start projects offer their clients a range of
support services, including onsite Medicaid/WIC eligibility certification,
transportation, child care, parenting information nutrition education, peer
support for young parents, adolescent empowerment and self-esteem activities,
home visiting, male involvement programs, substance abuse treatment and
counseling, housing and employment assistance.
Example: Northwest Indiana Healthy Start transports clients to prenatal care
and pediatric appointments in mobile "MOM" vans.
Example: The Baltimore City Healthy Start encourages men to be involved in
their partners' pregnancies and their children's lives through its Men's
Services Program, which has served as a model for the Nation. The program
requires fathers to attend prenatal care appointments and parenting classes,
while offering them a therapeutic support group in which to share their
feelings, successes and frustrations about fatherhood.
To address the differences in the health and infant mortality rates between
minorities and the general population. The lack of cultural sensitivity and the
ability to reach out to minority population groups often have impeded die
delivery of prenatal services. The projects have developed culturally sensitive
"one-stop" service centers within the community to ensure that services are
provided in a manner that is comfortable to culturally diverse populations.
Example: The Chicago project, which has the highest concentration of
Hispanics, has established Esperanza Hope, a "one-stop" shop with comprehensive
bilingual staff. This center has already reached capacity and has a waiting
list for prenatal care. These centers sponsor ethnic ceremonies, activities and
festivals and produce educational materials in languages appropriate for their
Example: In New Orleans, with its unique cultural heritage, Nanans
(godmothers) and Parrains (godfathers) identify residents who are pregnant
facilitate their entry into services, often transport the clients to care; and
provide counseling and health education.
In 1993, HRSA entered into a contract with Mathematica Policy Research, Inc.
to conduct cross-site evaluation of the 15 original Healthy Start projects This
national evaluation consists of both a process and outcome analysis. The basic
questions to be addressed are: Did the Healthy Start program succeed? If so,
why? If not, why not? And what would be required for a similar intervention to
succeed in another setting?
The process evaluation of Healthy Start will detail the individual
characteristics of the original fifteen Healthy Start projects, their health and
social service infrastructure, organizational characteristics, and descriptive
information about die type and scope of local interventions.
The outcome evaluation entails a quantitative analysis of the overall
success of the Healthy Start program through assessments of multiple program
outcomes such as infant mortality, low birthweight incidence, and improved
maternal and infant health, using client- specific data as well as secondary
data sources. The national evaluation is a 5-year effort, with a final report
due in 1998. To date, the following national evaluation tasks have been
Site visits in 1994 and 1996, with telephone follow-ups in 1995,
- Focus groups of providers and consumers at all project sites,
- Postpartum survey of approximately 2,800 women,
- Selection of comparison sites,
- Collection of client level data,
- Meetings of Technical Advisory Group in 1994, 1995, and 1996, to advise on
details of the study,
- Compilation of services available in each Healthy Start project site,
- Preparation of first and second year annual reports highlighting the
implementation and operational phases of the Healthy Start program, and
- Initial assessments of the sustainability efforts at each project site.
In addition to the national evaluation, the 15 original Healthy Start
projects have the administrative option of conducting local evaluations. Each
of the Special Projects is required to conduct local evaluation. These
evaluations are designed to monitor the implementation of project interventions
and/or assess more site- specific intervention strategies. A local Fetal and
Infant Mortality Review process is also being conducted utilizing both community
and professional committees to provide timely feedback on project interventions.
The Healthy Start Initiative also features an aggressive national and local
public information and education component that raises awareness of the problem
of infant mortality and promotes prenatal care and other healthy behaviors. The
highlight is a national public service campaign, developed with the assistance
of the Advertising Council. A recently developed set of public service
advertisements, which will be released this summer, urges women to avoid putting
their baby's health "on the line" by seeking early and regular prenatal care.
The campaign will feature two new toll-free numbers - one for English-speaking
callers and one for Spanish-speaking callers. These national prenatal care
hotlines will connect callers to the Healthy Start project or State maternal and
child health office closest to where they live.
When we look at Healthy Start, we see an Initiative that has been
instrumental in reforming systems of care in 22 communities. Those benefitting
from Healthy SW services range from women of childbearing age and infants to
community members throughout the Nation. Consider the sheer number of people
served in 1995 alone:
- 114,000 women of childbearing age received Healthy Start services.
- 18,000 teens participated in school-based health and/or teen pregnancy
- 48,000 adolescents participated in various other risk prevention programs.
- Over 20,000 babies were born to Healthy Start clients.
- 212,000 prenatal care encounters and 85,000 pediatric contacts were
- 32,000 families received transportation assistance to access needed
- 16,000 families took advantage of Healthy Start-funded child care
- Community outreach activities reached over 188,000 residents.
- Public education and media activities reached over 12 million residents.
As the initial Healthy Start demonstrations conclude, we in HRSA are
providing technical assistance to the projects in a number of ways designed to
sustain and replicate effective program models to decrease infant mortality,
- Assistance in making the Healthy Start program a permanent part of a
community's infrastructure. This includes skillfully packaging effective infant
mortality reduction strategies and marketing them to managed ;are providers.
- Assistance in transitioning Healthy Start projects to serve as mentors for
States or communities interested in establishing similar infant mortality
- Assistance in developing linkages with corporations, foundations and other
business entities, thereby forming enduring public and private sector
The support of the private sector has always been a main ingredient of
Healthy Start. In 1992, eleven private sector organizations including, among
others, March of Dimes, Kiwanis International, The Urban League and the
Washington Business Group On Health, formed a Healthy Start Steering Group to
provide advice to communities in leveraging the resources of local companies and
foundations. Johnson & Johnson chairs the Private Sector Steering Group. The
company has not only given tangible assistance in raising public awareness of
the tragic problem of infant mortality, but also sponsored a paid advertising
campaign with the message "It s never too early to give your baby a Healthy
Start." This public service campaign generated nationwide primetime coverage for
Healthy Start and helped the local projects reach people in need. Today Johnson
& Johnson is at the forefront of a new private sector effort-- to organize a
national summit of community and corporate leaders. This summit will allow the
Healthy Start program to showcase results and further enhance private sector
involvement in the national efforts to reduce infant mortality.
It has taken several years for the Healthy Start projects to identify the
unique contributing factors behind the high infant mortality rates in their
target populations and to find manageable solutions for their communities. With
a national investment of $460 million, the Healthy Start program has had
valuable impact in addressing health, social and economic issues beyond infant
mortality reduction. The Healthy Start experience with involving communities in
public health programs ought to be used as a learning lab for both urban and
rural communities across the country, especially for programs targeting low
income and underserved populations. I can say that we have indeed broadened our
knowledge base. It would be a tragedy to our Nation to halt our advances now.
Commencing with FY 1997, we plan to take the lessons learned to date and
build on these successful experiences through a two-pronged approach that will
maximize the use of financial resources, as well as knowledge and experience.
Many of the current projects will be continued with an additional role - - that
is, these projects will become "teachers", sharing the "how to" of their
successes and the "what" and how "not to" from their experiences and knowledge.
Their "students"will be other communities and States, suffering from the ravages
of high infant mortality and low birthweight infants, desirous of putting in
place the mechanisms to address their particular situation. We will call these
"teachers" Healthy Start Resource Centers, mentoring to those seeking
knowledge,while also continuing their effective strategies within their own
communities. The second prong of our approach will be the funding of new
communities to operationalize successful models applicable to their respective
communities, building coalitions, and the mechanisms for sustainability - -
eventually themselves becoming Resource Centers. This approach will further
expand integration of State/local Title V programs and other existing maternal
and child health services. We believe this plan will maximize the efficient use
of resources and their impact on infant mortality, reduction.
In closing my prepared testimony, I would like to emphasize that Healthy
Start is a driving force for empowering individuals and communities to take
charge, promoting healthy mothers, infants and families, building stronger
communities, States, and a Nation, to take on tomorrow's challenges, while
conserving future resources.
This concludes my testimony. We will be happy to answer any question you