cumstances in which OEO funds can be used for hospitalization should be defined on a programwide basis. Target area residents were employed and trained by the centers and, in general, were involved in policymaking and operation of the centers. However, they were not always involved in the decisions to establish the centers or in the initial planning. The OEO program is only one of the approaches in an increasing Federal effort to deal with the shortage of health professionals and the rising cost of health care. HEW has also begun funding neighborhood health centers under its partnership for health program and has given high priority under the Comprehensive Health Planning and Public Health Services Amendments of 1966 to funding programs aimed primarily at the improvement of the health status of the medically indigent. The program also includes training and utilization of the poor and their involvement in the planning and implementation of projects. Although both the OEO and HEW programs require periodic evaluations, no uniform evaluation schemes have been developed. We believe that such schemes are needed to provide for comparisons of the effectiveness of programs having similar objectives. Our contractor also found that, within the OEO program, evaluations had not yet been performed to determine which of the various methods of providing health care being tested and demonstrated at the different centers are most successful in achieving overall program objectives. We believe that, although the program has not been in operation a sufficient length of time for full evaluation, the methods should be evaluated during their development phase to assess their long-range implications and to provide a basis for revising goals or practices that appear to be inconsistent with the resources that can reasonably be expected to be available in the future. In this connection, we question whether, because of the high costs involved and the general shortages of medical personnel and hospital facilities, certain of the methods and practices being tested at the Chicago center represent a fully practicable demonstration of new and innovative means to bring services to the medically indigent, which could be applied nationally. For example, the center's latest proposal, in effect, requested funds for a staff of pediatricians in the ratio of 32 for each 100,000 people, whereas nationwide there are available only about eight pediatricians for each 100,000 people. FAMILY PLANNING For this program, our contractor examined the costs and benefits of both HEW and OEO family planning efforts. This analysis utilized data obtained from the community action program management information system, from OEO neighborhood health centers, and from projects being operated under HEW's maternal and infant care, and maternal and child health grants. Also, we reviewed financial and participant data at 11 locations. Our contractor found that many studies have demonstrated that exceptionally high benefits to the poor family and to the public sector could derive from family planning services, but that little data was available to permit an evaluation of the effectiveness of family planning programs in terms of alleviating poverty. One of the contributing factors to the limited availability of such data is the relatively recent origin of the programs. It was not possible to obtain a reliable estimate of the cost of providing family planning services. Our contractor found that the average cost for each participant in family planning programs varied between $20 and $50. Part of the difficulty was inadequate cost data; however, of perhaps more importance, was the lack of reliable figures on the number of participants and the services provided. In this connection, however, ÓEO, HEW, and Planned Parenthood-World Population are cooperating in the development of a uniform patient data reporting system, with HEW assigned primary responsibility, that will include participant characteristics, services provided, baseline birth rates, and the birth rates experienced by participants in the program. Our analysis of financial and participant data at 11 locations offering family planning services funded by OEO further indicated a wide range in the cost for each participant at the various locations. We noted that, although the procedures used by these 11 projects for reporting data to OEO varied considerably and the data reported was limited in scope, consistency, and accuracy, the projects experiencing the higher unit costs were generally in rural areas, used door-to-door solicitation, and/or were strictly family planning clinics which were open long hours. The projects experiencing lower unit costs generally were in urban areas, received free publicity and referrals from OEOfunded neighborhood centers and other social agencies, and/or used existing facilities on a part-time basis with extensive voluntary help. OTHER CAP HEALTH SERVICES We examined two health projects being funded by OEO: a health clinics project in Detroit, which is carried out as a separate locally initiated component of the city's CAP, and an Indian home health project. ÓEO reported that obligations for the neighborhood health clinics. project in Detroit from inception in January 1965 through August 1968 amounted to about $3.1 million. The project is intended to bring outpatient health services to target poverty areas. We found that the health services were not always directed to intended beneficiaries, that the CAA had not been effective in mobilizing existing health resources of the community, and that preproject emergency treatment and hospitalization services had generally not been improved by the project. The homemaker-health aide project on the White Earth Indian Reservation in Minnesota, with expenditures of about $34,250 in Federal funds from inception in June 1967 through March 1968, was intended to train and utilize reservation residents in providing homemaking and home nursing services in the homes of needy families. Although indications were that the project as administered was favorably accepted by the participants, it appeared that the project replaced a similar project operated on the reservation by a local agency of the State department of health. Also, while a lack of adequate records precluded a determination of the degree to which the project accomplished its objectives or the efficiency with which the project was administered, we were advised by a Public Health Service official on the reservation that the project had resulted in reducing lengths of confinement in hospitals and nursing homes and the cost for such care. Chapter 7 EDUCATION PROGRAMS Programs authorized by the Economic Opportunity Act, which provide for educational activities, include Headstart, Upward Bound, and education programs initiated locally by community action agencies (CAA). These programs are discussed in the following sections of this chapter. A discussion of the educational aspects of the manpower, legal services, and migrant and seasonal farmworkers programs is included in the chapters dealing with these programs. HEADSTART The Headstart program is designed to assist economically disadvantaged preschool children to achieve their full potential. Its broad objectives are to improve the child's health; aid the child's motivational, social, and emotional development; improve and expand the child's ability to think, reason, and speak clearly; and help both the child and his family gain greater confidence, self-respect, and dignity. To meet these objectives, OEO has prescribed a variety of services and activities for the child and his family, such as health, nutritional, educational, psychological, and social services. Parent participation in the classroom as paid employees, volunteers, and observers is emphasized to stimulate parental involvement in the child's development. Parent education and participation in the management of projects at the local level are also emphasized. With respect to volunteers, OEO guidelines suggest the use of college and high school students, in addition to parents. Other particulars of this program are described in greater detail in appendix I, page 175. OEO reported total obligations of $960.6 million for Headstart projects and activities from its inception in 1965 through fiscal year 1968. OEO reported also that about 2.1 million children had participated in summer Headstart projects and about 600,000 in fullyear projects. Federal financing for the Headstart projects at the three locations where we made field examinations-two urban and one rural-totaled $4 million from inception of the individual projects through the 1968 program year. We reviewed the operating records of 16 full-year and 15 summer Headstart programs functioning in 23 different cities as part of our assessment of the Community Action Program Management Information System. We obtained responses to questionnaires sent to the responsible local officials at 80 Headstart centers. CONCLUSIONS 1. Because of the potential long-range effects of the Headstart program, only interim judgments can be made at this time and then only on those effects which have short-term visibility and which have measurable impact. Further, the measures used have uncertain pre ciseness because of the limitations of testing techniques when applied to preschool disadvantaged children, the impracticality of obtaining fully comparable control groups, and the personal bias of those closely involved in the program, particularly teachers, to whom questions have been directed on their experiences with the children. 2. From the results of such testing techniques as were available to us, it appeared that, at the locations where we made field examinations, children who had participated in Headstart usually made modest gains in social, motivational, and educational areas although the period of benefit retention for summer program participants seemed to be relatively short. It appeared further that children who had participated in Headstart were generally better prepared for entry into the regular school system than their non-Headstart counterparts. 3. Many children benefited in varying degrees from the medical, dental, and mental health services; the well-balanced meals; and the group instruction activities made available to them through the Headstart projects; however, certain children did not receive all these benefits because of delays in providing medical and dental services. 4. The program was less successful in employing parents, encouraging them to participate as volunteers or observers, or promoting their participation in education programs. Involvement of the parents in the children's activities is the basic element for building the relationship between parents and their children and is vital to developing the confidence, self-respect, and dignity which are primary objectives. of the program. More concentrated effort in this respect is necessary if the objectives of parental involvement are to be effectively met. Although we do not disagree with the merits of OEO's policy of retaining parents as paid employees after their children have left the program so as to provide such parents with career development opportunities through Headstart training, this aspect of program policy should not be emphasized to the extent that it becomes detrimental to the objective of involving parents whose children are enrolled in the projects. 5. Some children may have been prevented from participating in the projects because eligibility criteria were not properly applied or classroom space was not fully utilized. RECOMMENDATIONS In accordance with the foregoing conclusions, we made the following recommendations: 1. That OEO direct and assist local project officials to make further efforts to involve more parents in the program. 2. That OEO monitor the projects to ensure a proper balance between parents of Headstart children and parents of former Headstart children who are participating in the projects as paid aides. In our supplementary reports on the community action programs (CAP) examined at individual locations, we are making specific recommendations for improvement. PROGRAM RESULTS It appeared, on the basis of test scores and/or teacher evaluations at two locations for both full-year and summer programs, that the |