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Grants-in-aid in Federal-State Dental Public Health Program Relationships
182 • THE J O U R N A L O F T H E A M E R IC A N D EN T A L A S S O C IA T IO N
not new-—they have evolved during the past century and a quarter. The dental divisionis a functional unit withinthe administrative structure of the department of health. Organizeddentistry has recommended that the dental pro grambe one of the basic health services of the state department of health. The dental divisionhas athree-fold re sponsibility to discharge: a responsibility to the dental profession, a responsibility tothepublichealthagency, andarespon sibility to the population served. The areas of activity include those which af ford an indication of the extent of the problems, a notion of the most useful methodfor the reductionof the problem, andameans for the determinationof the effectiveness of theprogram. Thescopeandtheextentoftheprogram of thedental divisionwill bedirectlypro
portional to the amount of funds which aremade available for its operation. It is obvious that themost important factor in the determination of the effectiveness of the dental division of the department of public health is the relationship which exists betweenthedental divisionandthe dental profession. Modern dental public health arose as the direct result of the activities of the members of the dental profession. The dental division of the statedepartment of healthis the result of thejoiningtogetherof organizeddentistry and official public health. It must not be forgotten that the cooperative support and assistance provided by these, the parent organizations, will determine the effectiveness of the dental division in its efforts to improve the healthof the com munity by the improvement of the com munity’s dental health.
G R A N T S -IN -A ID IN F E D E R A L -S T A T E D E N T A L P U B L IC H E A L T H P R O G R A M R E L A T IO N S H IP S
Norman F. Gerrie, D.D.S.,
Forthepast 38 yearsfederal grants-in-aid have been utilized for public health pur poses by state and local units of govern ment.1The historical development of the grant-in-aid principle as ameans of pro vidingfinancial assistancetogovernments with limited financial resources has been considered in detail by many students of public health administration.1'5 A current list of identifiable health grants would include those for maternal and child health and crippled children’s services derived fromTitle V of the So cial SecurityAct; thegrants administered by the Public Health Service for the fol lowingpurposes: general health services; venereal diseasecontrol; tuberculosiscon trol; cancer control; mental health; hos pital survey and construction; heart dis ease control; poliomyelitis vaccine dis
Washington, D. C.
tribution, and the basic support grants of the Office of Vocational Rehabilita tion. It is generally acknowledged that the grants-in-aid have been highly effective instimulatingthe state and local governA ssistant c h ie f Service.
d e n ta l
o ffic e r,
U.
S.
P u blic
H e alth
1. M ou n tin , Joseph W ., and G re v e , C liffo r d H . Role o f g ra n ts -in -a id in fin a n c in g p u b lic hea lth pro g ra m s. P u blic H e a lth B ulletin 303. W a s h in g to n , D. C ., G o v e rn m e n t P rin tin g O ffic e , 1949. 2. W h ite House C o nfe ren ce on C h ild H e a lth and P ro te c tio n . Public^ hea lth o rg a n iz a tio n ; section II. P u b lic health service and a d m in is tra tio n . New York, C e n tu ry C o ., 1932. 3. M o u n tin , Joseph W . F ina ncing local ices— fe d e ra l p a r tic ip a tio n . Pub. H e a lth O c t. 1952.
hea lth serv Rep. 67:944
4. H a nlon, J . J . P rincip les o f p u b lic health a d m in is tra tio n , e d . 2. St. Louis, C . V. M osby C o ., 1955. 5. M ou n tin , Joseph W .; H a nkla, Em ily, and Druzina, G e o rg e B. Ten years o f fe d e ra l g ra n ts -in -a id fo r p u b lic hea lth, 1936-1946. P ublic H e a lth B u lle tin 300. W a s h in g to n , D. C ., G o v e rn m e n t P rin tin g O ffic e , 1951.
SEVENTH N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E . . . V O L U M E 54, FEBR U A RY 1957 • 183
ments to establish new health programs, to expand and improve existing pro grams, to raise standards and to secure and train more competent personnel.3 The incentives afforded by joint effort towardthoseobjectives has resultedinan effective working partnership of federal, state, and local health governments.6To secure grant funds, the health agency is required to spend its own funds for the sameobjectives as those supported by the grant fund. The ratio of these matching funds to grant funds is usually one dollar fromstate or local sources to two dollars fromfederal sources. Under existing grant authority the state agency may determine, subject to approval by the federal agency con cerned, whether grant funds will be used to support state administered services or whether they will be usedfor locally ad ministeredservices.3Statepractice inthis respect varies, dependent onwhether the state provides a large degree of direct health services or furnishes financial as sistance to the local health agencies for health purposes. In either case, the re distribution of grant funds by the state is modified by the ability of the local area tosharethecost; the poorer communities receive relatively more aid in accordance with the basic objective of grants-in-aid. In the allocation of grant-in-aid funds, in most- instances, the law establishing the grant incorporates, in general terms, the method of apportionment. These terms, described as the “allocation pro cedure,” apply to all forms of grants. A brief description of the project and variable allocation types of grants may serve to illustrate the most commonly usedmethods of distributinggrant funds.
physical facilities. The project grant places emphasis on initiative in develop ing projects and aids most the health agencywhichiswillingandabletospend its own funds. The Hospital Survey and Construction Act of 1946, as Amended (Hill-Burton Act), provides an excellent example of the incentive afforded by project grants in the construction of hos pital andothermedical facilities. The states were enabled through HillBurton grant funds to make surveys of their existing health facilities, and to de velop comprehensive state-wide plans which designated areas and localities in need of particular kinds of facilities, as signing a priority to each. Applications for project grant funds were theninvited fromeligiblesponsoringgroups, organiza tions andagencies. Each facility was built and equipped by a sponsor which paid fromone third to two thirds of the cost, depending on the financial status of the state in which the project was located. The finished facility, while fulfilling the needs of the community in which it was located, at the same time made its contribution to wardsatisfyingtheover-all healthfacility requirements of the regional.and state plan. In the nine years during which this grant program has been in operation, 2,000 medical facilities of various types havebeenconstructed. Total cost of these projects was $1,505,000,000, of whichthe sponsors paid $990,000,000, the federal share being $515,000,000. No monetary value can be estimated for the health benefits received by the populations servedby these projects. V A R IA B L E
P R O J E C T G R A N T A L L O C A T IO N
A L L O C A T IO N
Wide differences exist inthe states inthe To qualifyfor thesegrant funds, thestate service requirements of programs and in or communitymust submit aplanfor the proposed project. This method of alloca 6. Mountin, Joseph W ., and Fiook, Evelyn. Guide to health organization in the United States 1951. Public tionishighlyeffectiveinthedevelopment Health Service Publication 196. Washington, D. C., of basic research and construction of Government Printing Office, 1953.
184 . THE J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
their ability to provide funds for even a minimum program. To meet this need, a variable allocation formula is required in order to compensate for these differ ences between states. The yardstick em ployed in the formula considers several factors which measure service require ments andfiscal capacity. Populationis used as anindex of serv ice requirements, and, when the benefits of the grant program reach every one, the total population is used. Under other circumstances, the population factor is restricted to those groups who would benefit from the grant.1 Another factor involved in determining service require ments isthemagnitude orintensityof the problemin the individual state. Inclusion in the formula of measure ments of the financial need and fiscal capacityof theagencyreceivingthegrant also presents difficulties. The grant formula endeavors to distributethefunds so that a poor area is required to spend less of its own funds in order to receive relatively more grant funds. Per capita income is considered to be the best measurement of the relative abilityof the states to pay for health services.1 A typical example of a grant program using a variable allocation formula of population, per capita income and ex tent of problem is the venereal disease control program. This is the oldest grant program, having been initiated in 1918. Allotments of venereal disease control grant funds are made to the states ac cordingto aformula whichprovides that from20 to 40 per cent of allotment shall be on the basis of population, weighted byfinancial need; and from60 to 80 per cent on the basis of extent of the prob lem. These funds have aided the state and local health departments to develop clinics for the treatment of venereal dis easepatientsthroughout thecountry. The number of such cooperative clinics rose from656 in 1935 to 3,324 in 1946. Dur ingthe last war thestateandlocal health
departments, by- tracing and treating Se lective Service registrants reported as in fected, made many thousands available for military service. At the same time, rapid treatment centers were established with grant funds in 38 states for treat ment of early syphilis. The new, rapid methods employed in these centers have reduced the treatment periodfor this dis ease from 18 months to two weeks, and for gonorrhea to a single visit. An im portant effect of this reduction in treat ment time has been the decrease in the number of venereal disease treatment centers to 2,113 as of 1955. G R A N T S - IN - A ID AND
LOCAL
AND
H EA LT H
STATE S E R V IC E »
Although it is sometimes difficult to as sign credit appropriately, the following constructive developments occurred dur ingthe tenyear period subsequent to the real beginningof grants-in-aidtostatesin 1936, the year in which the Social Se curity Act was passed: 1. Per capita state appropriations for health purposes increased for all states, rising from an average of 10/i cents to 26 cents. Total annual appropriations by states increased from $13,258,000 to $33,560,000. Meanwhile the amount of federal grants paid to states rose from about 7% million dollars to'11 million dollars annually. This would indicate that federal grants-in-aid, instead of re tarding, stimulate the financial participa tion of state governments in health activities. The increasedfunds fromboth sources have been used to support the state health department structure and the activities conducted by state per sonnel. In addition, they provided finan cial assistance to local health units, labo ratories, and special health projects operated by counties, cities, and other political subdivisions. Duringthetenyear period, local appropriations for health purposes increased from22^2 to 59 mil
SEVENTH N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E . . . V O L U M E 54, FEBR U A RY 1957 • 185
lion dollars. The estimated expenditures from all sources by state health depart ments for dental activities underwent a concurrent rise from $37,000 in 1930 to $708,000 in 1946. 2. In the period 1940 to 1946, full time personnel employed by state health departments increased from 10,128 to 12,414, an increase of 23 per cent. The number of full-time dentists, ontheother hand, fell from124 to 79, probably asthe result of war-relatedhandicaps inobtain ing personnel. However, although the number of dentists decreased by one third, the funds expended for dental public health purposes increased almost twentyfold over expenditures in 1930. One possible explanation for this seem ing inconsistency might be the growth during this period of local dental public health programs which absorbed funds fromstate and local sources without re quiring additional state personnel. 3. There were only 18 state health departments with identifiable dental projects in 1935. Despite the prevalent shortage of dental personnel, thenumber increased to 35 by 1940 and to 39 by 1946. (At the present time all states but one, Arizona, have provision for state dental public health programs.) These stateprograms conductededucational ac tivities, promoted and organized local dental programs, and provided dental consultation service to local health de partments as well as to private dentists, dental hygienists, physicians, nurses, and others. Many states conducted surveys of selected population groups to determine the influence of certain factors on dental health. In a few instances, by financial assistance or by furnishing personnel, they provided special dental services to limitedgroups inthe population. G R A N T - IN - A ID AND
toits administration are embodied inthe Act, setsforththebasisfor administrative relationships between the governmental agencies involved. The consultant rela tionships resulting from this administra tive requirement are concerned chiefly withplans, fieldservices, andrecords and reports. These items constitute the basis for the establishment and conduct of the consultant services developed by the federal government for administering grants-in-aid. The legislative provision requiring re viewof plans bythe granting agency has some obvious advantages. One of these is the assurance of some degree of uni formityinprogramoperation. Again, the quality of service is improved by the op portunity to exchange ideas and benefit from a broad range of experience and understanding. Field services offer an opportunity for stimulation and encouragement on a col laborative basis in dealing with problem areas in the dental program. The records and reports required by the granting agency offer an excellent means for joint consideration of the effectiveness of the program conducted by the recipient of the grant. In this re gard, recent developments indental pro gramanalysis indicate that the process of programevaluation is almost inseparable fromprogramplanning, once a program is under way. The basic document re quired of the states by the Public Health Service is termed the “State Public HealthPlan”; however, amoreobjective, but unofficial, type of record for setting forth the state dental program plan has been developed during recent years.7 This plan record, although not required, has the advantage of incorporating pro cedures for programevaluation and is in use in many of the states.
A D M IN IS T R A T IO N
F E D E R A L C O N S U L T A T IO N
The legislativeactioncreatingagrant-inaid, by the fact that conditions essential
7. Knutson, J . W . A c c o m p lis h m e n ts th a t may be achie ved and m ethods o f e v a lu a tin g local p u b lic health d e n ta l p ro g ra m s . A m .A . Pub. H e a lth Den. Bui. 13:1 Feb. 1953.
186 • THE J O U R N A L O F T H E A M E R IC A N D EN T A L A S S O C IA T IO N
their usein combatting the dental health problem; and cooperate with state and local health, education, and other activi Consequent to the utilization of federal ties in the conduct of projects in dental grant-in-aid funds in state dental pro public health. grams, the federal government provides technical andconsultant dental personnel N O N D E N T A L G R A N T - IN - A ID F U N D S to carry out its function in the adminis AND DEN TAL PROGRAM S trationof the grant funds. The principal structure through which There are a wide variety of federal these responsibilities are conducted at grants-in-aid for health purposes. Al thefederal level iscomposedof thedental though none of these grants provide advisory services of the Children’s specifically for dental activities, the ob Bureau, and the Bureauof State Services jectives of several are sufficiently broad andits Divisionof Dental Public Health, to permit use of their funds for dental where dental public health activities are programs in the states. centralized within the Public Health Under provisions of the maternal and Service. Regional offices constitute ex child health grants-in-aid, a large num tensions of the Bureau which maintain berof statedental publichealthprograms intimate functional relations with the have been established since 1935. At the states. Consultant dental personnel, under present time, 41 state dental programs the technical supervision of the Division utilizethesefunds, amountingtoapproxi of Dental PublicHealth, staff theregional mately$800,000 annually, for administra offices and maintain working relations tion and operation. withtheircounterparts inthestatehealth Cancer control grant funds allotted to departments. statehealthdepartments are usedto con These consultant personnel are re duct institutes and seminars on oral can sponsible for the conduct of functions cerforpracticingdentists, andtoproduce related to the administration of grant and distribute literature on oral cancer. funds of the Public Health Service, In The Assistance to States General addition, theyact as technical consultants grants-in-aid of the Public Health Serv to the nondental regional representatives ice is used to the extent of about of the Children’s Bureau. They serve also $100,000 annually for basic services in as consultants at the regional level to the seven state dental programs. construction grant program of the Di The total expenditure for state dental vision of Hospital and Medical Facili programs budgeted for the 1954-5 fiscal ties of the Bureau of Medical Services, year was $2,133,443. Of this amount, ap Public Health Service, and to other proximately 42 per cent came from regional consultant personnel. grant-in-aid programs administered by Unrelated to grant administration the Public Health Service and the Chil functions, but carried out as a function dren’s Bureau. derived frombasic Public Health Service legislation,8 the regional dental con IN A D E Q U A C IE S O F N O N D E N T A L sultants, both independently and in co G R A N T S - IN - A ID operation with state and local dental program personnel, conduct investiga Because of the lackof earmarked federal tions of the extent and nature of general grant funds, state dental programs have and specific dental problems. They de termine resources available for dental 8. The P u blic H e a lth Service A c t (58 S tat. 682, 42 public health application and encourage USC 201 et. s e q .): as a m ende d. RO LE OF FEDERAL
D EN TAL
C O N SU LTAN TS
SEVENTH N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E . . . V O L U M E 54, FEBR U A RY 1957 • 187
had to rely mainly on other federal cate gorical grants with dental-related aspects for funds tosupplement thefiscal support of state appropriations. Although, in some states, there is an earmarked state appropriation for the dental program, state appropriations for general health purposes create a situation in which the dental program must compete on un favorable terms with other health activi ties for a share of limited state health funds. Frequently the noncategoricail general assistance grant funds are exhausted by the basic administrative and programre quirements of the state health depart ment, leavinglittleornoneforthosecate gorical health programs which possess no specific grant funds. This inadequacy in financial support results in serious re striction in the scope and emphasis of state dental program activities. The skeletal staffs which exist in many state dental programs are unable to devote morethanlipservicetothedental aspects of chronic illness, dental problems of the aging, topical fluoride programs and the promotionof fluoridation. Also, technical competence at the state level should be available to aid communities in the de velopment of local dental programs. With few exceptions, understaffed state dental programs are unable to provide this assistance. Furthermore, state pro grams to a large extent are not able to make essential, basic, comprehensive studies of the nature and extent of their dental health problems, from which to develop methods for the prevention and control of dental diseases. Exceptions to the foregoing do exist in such states as Tennessee and Michigan, where sizable appropriations of state funds augment funds available from grant sources. In these states the range and extent of dental public health activi ties have been substantially increased by the addition of dental personnel to the state staff. All-in-all, the lack of adequate funds
is a major deterrent to development of statedental programs. The small fraction of total health funds available fromcur rent sources for dental public healthpro grams clearlyindicates thepotential value of a categorical dental grant in stimulat inggrowthof dental activities at thestate and community levels. U S E O F C A T E G O R IC A L D E N T A L G R A N T S - IN - A ID
It is expected that a special grant-in-aid appropriation for dental health purposes would be used by the states to support and strengthen such basic dental public health services as: 1. Training of dental division staff members and private dentists who par ticipate in the dental public health pro gram. 2. Health education programs and studies of methods tomakemore effective the interpretation of the benefits of good dental health to the public. 3. Establishment and maintenance of community dental service clinics. 4. Promotional programs designed to interest communities in the application of effective methods and procedures for thecontrol of dental diseases. 5. Addition of personnel for the con duct of topical fluoride programs inrural areas. 6. Provision of expert consultation and guidance to local dental programs in utilizing effective technical and ad ministrative procedures. 7. Specific research studies such as those directed toward investigation of epidemiological characteristics of dental disease or in administrative research di rectedtoward the solutionof operational problems. 8. In-service trainingfor state or local personnel. 9. Utilization of undergraduate den tal students in program operations as a recruitment device, to expand their in terest in dental public health work, and
188 • T H E J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
increase the number of dental public considerations focus on plans, field serv ices, and records and reports. The health workers. 10. Technical guidance andassistanceperformanceof theseadministrativefunc to teacher training schools in strengthen tions by the federal government consti tutes the basis for the establishment and ing dental phases of health teaching. More extensive utilization of grant-in- conduct of consultant services to states. aid funds for dental program purposes Regional dental consultants and their wouldpermit theadditionof dentists and staffs fulfill this responsibility in the other professional persons to the staffs of regional office of the PublicHealth Serv state and local health departments to ice, affording opportunities for working meet the demandfor services where such relationships with state and local dental demand already exists, or to stimulate personnel injoint considerationof dental interest in dental activities where none public health programs. Because of this exists. At the present time, no other administratively derived relationship, the means for providing adequate, essential conduct of dental public healthprograms becomes a working partnership of the community support seems available. three units of governmental health serv ice. SU M M A R Y State and local dental public health The federal grant-in-aid system is a programs are dependent for financial method devised for the purpose of support, fromother than state and local equalizing, between the poorer and the sources, on several nondental grants-inmore wealthystates, the burden of finan aid. Justificationforobtainingfundsfrom cial support for state and local govern thesegrant sources isbased onthe dental mental health services. This procedure aspects of the health problemfor which provides proportionately more assistance the grant was appropriated. The inade to the poorer states where fiscal resources quacy of funds fromthese sources is evi are inadequate. In so doing, the grants dent, andpoints tothe needfor increased systemhas been effective in stimulating dental programfundsfromgrant sources. the establishment of new health pro There are many constructive purposes grams, expansion and improvement of towhich additional grant funds could be existing programs, raising standards of devoted. operation, and in securing and training From the foregoing observations it competent personnel. should be apparent that grant-in-aid Funds are allotted to the states in the funds are anessential factor inproviding form of grants, and are then reallotted financial assistance to states for the pur to local health agencies or expended in poseof stimulatingthe establishment and direct state services. Matching funds conduct of public health programs, and fromstate and local sources are required for stimulating increased state and local to obtaingrant funds. appropriations for health purposes. Al The granting agency influences the though dental public health programs grant program by requiring that the have shared in this process, and have grant recipient adopt certain minimum undergone a degree of development and standards for program administration expansion since the general application and operation and spend the funds for of the grant principle was initiated in the purposes for which they were ap 1935, there is considerable room for propriated. Inthefunctioningof federal- additional progress and improvement in state relationships derived from the this area of federal, state, and local rela administration of grant-in-aid funds, tionships.
not new-—they have evolved during the past century and a quarter. The dental divisionis a functional unit withinthe administrative structure of the department of health. Organizeddentistry has recommended that the dental pro grambe one of the basic health services of the state department of health. The dental divisionhas athree-fold re sponsibility to discharge: a responsibility to the dental profession, a responsibility tothepublichealthagency, andarespon sibility to the population served. The areas of activity include those which af ford an indication of the extent of the problems, a notion of the most useful methodfor the reductionof the problem, andameans for the determinationof the effectiveness of theprogram. Thescopeandtheextentoftheprogram of thedental divisionwill bedirectlypro
portional to the amount of funds which aremade available for its operation. It is obvious that themost important factor in the determination of the effectiveness of the dental division of the department of public health is the relationship which exists betweenthedental divisionandthe dental profession. Modern dental public health arose as the direct result of the activities of the members of the dental profession. The dental division of the statedepartment of healthis the result of thejoiningtogetherof organizeddentistry and official public health. It must not be forgotten that the cooperative support and assistance provided by these, the parent organizations, will determine the effectiveness of the dental division in its efforts to improve the healthof the com munity by the improvement of the com munity’s dental health.
G R A N T S -IN -A ID IN F E D E R A L -S T A T E D E N T A L P U B L IC H E A L T H P R O G R A M R E L A T IO N S H IP S
Norman F. Gerrie, D.D.S.,
Forthepast 38 yearsfederal grants-in-aid have been utilized for public health pur poses by state and local units of govern ment.1The historical development of the grant-in-aid principle as ameans of pro vidingfinancial assistancetogovernments with limited financial resources has been considered in detail by many students of public health administration.1'5 A current list of identifiable health grants would include those for maternal and child health and crippled children’s services derived fromTitle V of the So cial SecurityAct; thegrants administered by the Public Health Service for the fol lowingpurposes: general health services; venereal diseasecontrol; tuberculosiscon trol; cancer control; mental health; hos pital survey and construction; heart dis ease control; poliomyelitis vaccine dis
Washington, D. C.
tribution, and the basic support grants of the Office of Vocational Rehabilita tion. It is generally acknowledged that the grants-in-aid have been highly effective instimulatingthe state and local governA ssistant c h ie f Service.
d e n ta l
o ffic e r,
U.
S.
P u blic
H e alth
1. M ou n tin , Joseph W ., and G re v e , C liffo r d H . Role o f g ra n ts -in -a id in fin a n c in g p u b lic hea lth pro g ra m s. P u blic H e a lth B ulletin 303. W a s h in g to n , D. C ., G o v e rn m e n t P rin tin g O ffic e , 1949. 2. W h ite House C o nfe ren ce on C h ild H e a lth and P ro te c tio n . Public^ hea lth o rg a n iz a tio n ; section II. P u b lic health service and a d m in is tra tio n . New York, C e n tu ry C o ., 1932. 3. M o u n tin , Joseph W . F ina ncing local ices— fe d e ra l p a r tic ip a tio n . Pub. H e a lth O c t. 1952.
hea lth serv Rep. 67:944
4. H a nlon, J . J . P rincip les o f p u b lic health a d m in is tra tio n , e d . 2. St. Louis, C . V. M osby C o ., 1955. 5. M ou n tin , Joseph W .; H a nkla, Em ily, and Druzina, G e o rg e B. Ten years o f fe d e ra l g ra n ts -in -a id fo r p u b lic hea lth, 1936-1946. P ublic H e a lth B u lle tin 300. W a s h in g to n , D. C ., G o v e rn m e n t P rin tin g O ffic e , 1951.
SEVENTH N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E . . . V O L U M E 54, FEBR U A RY 1957 • 183
ments to establish new health programs, to expand and improve existing pro grams, to raise standards and to secure and train more competent personnel.3 The incentives afforded by joint effort towardthoseobjectives has resultedinan effective working partnership of federal, state, and local health governments.6To secure grant funds, the health agency is required to spend its own funds for the sameobjectives as those supported by the grant fund. The ratio of these matching funds to grant funds is usually one dollar fromstate or local sources to two dollars fromfederal sources. Under existing grant authority the state agency may determine, subject to approval by the federal agency con cerned, whether grant funds will be used to support state administered services or whether they will be usedfor locally ad ministeredservices.3Statepractice inthis respect varies, dependent onwhether the state provides a large degree of direct health services or furnishes financial as sistance to the local health agencies for health purposes. In either case, the re distribution of grant funds by the state is modified by the ability of the local area tosharethecost; the poorer communities receive relatively more aid in accordance with the basic objective of grants-in-aid. In the allocation of grant-in-aid funds, in most- instances, the law establishing the grant incorporates, in general terms, the method of apportionment. These terms, described as the “allocation pro cedure,” apply to all forms of grants. A brief description of the project and variable allocation types of grants may serve to illustrate the most commonly usedmethods of distributinggrant funds.
physical facilities. The project grant places emphasis on initiative in develop ing projects and aids most the health agencywhichiswillingandabletospend its own funds. The Hospital Survey and Construction Act of 1946, as Amended (Hill-Burton Act), provides an excellent example of the incentive afforded by project grants in the construction of hos pital andothermedical facilities. The states were enabled through HillBurton grant funds to make surveys of their existing health facilities, and to de velop comprehensive state-wide plans which designated areas and localities in need of particular kinds of facilities, as signing a priority to each. Applications for project grant funds were theninvited fromeligiblesponsoringgroups, organiza tions andagencies. Each facility was built and equipped by a sponsor which paid fromone third to two thirds of the cost, depending on the financial status of the state in which the project was located. The finished facility, while fulfilling the needs of the community in which it was located, at the same time made its contribution to wardsatisfyingtheover-all healthfacility requirements of the regional.and state plan. In the nine years during which this grant program has been in operation, 2,000 medical facilities of various types havebeenconstructed. Total cost of these projects was $1,505,000,000, of whichthe sponsors paid $990,000,000, the federal share being $515,000,000. No monetary value can be estimated for the health benefits received by the populations servedby these projects. V A R IA B L E
P R O J E C T G R A N T A L L O C A T IO N
A L L O C A T IO N
Wide differences exist inthe states inthe To qualifyfor thesegrant funds, thestate service requirements of programs and in or communitymust submit aplanfor the proposed project. This method of alloca 6. Mountin, Joseph W ., and Fiook, Evelyn. Guide to health organization in the United States 1951. Public tionishighlyeffectiveinthedevelopment Health Service Publication 196. Washington, D. C., of basic research and construction of Government Printing Office, 1953.
184 . THE J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
their ability to provide funds for even a minimum program. To meet this need, a variable allocation formula is required in order to compensate for these differ ences between states. The yardstick em ployed in the formula considers several factors which measure service require ments andfiscal capacity. Populationis used as anindex of serv ice requirements, and, when the benefits of the grant program reach every one, the total population is used. Under other circumstances, the population factor is restricted to those groups who would benefit from the grant.1 Another factor involved in determining service require ments isthemagnitude orintensityof the problemin the individual state. Inclusion in the formula of measure ments of the financial need and fiscal capacityof theagencyreceivingthegrant also presents difficulties. The grant formula endeavors to distributethefunds so that a poor area is required to spend less of its own funds in order to receive relatively more grant funds. Per capita income is considered to be the best measurement of the relative abilityof the states to pay for health services.1 A typical example of a grant program using a variable allocation formula of population, per capita income and ex tent of problem is the venereal disease control program. This is the oldest grant program, having been initiated in 1918. Allotments of venereal disease control grant funds are made to the states ac cordingto aformula whichprovides that from20 to 40 per cent of allotment shall be on the basis of population, weighted byfinancial need; and from60 to 80 per cent on the basis of extent of the prob lem. These funds have aided the state and local health departments to develop clinics for the treatment of venereal dis easepatientsthroughout thecountry. The number of such cooperative clinics rose from656 in 1935 to 3,324 in 1946. Dur ingthe last war thestateandlocal health
departments, by- tracing and treating Se lective Service registrants reported as in fected, made many thousands available for military service. At the same time, rapid treatment centers were established with grant funds in 38 states for treat ment of early syphilis. The new, rapid methods employed in these centers have reduced the treatment periodfor this dis ease from 18 months to two weeks, and for gonorrhea to a single visit. An im portant effect of this reduction in treat ment time has been the decrease in the number of venereal disease treatment centers to 2,113 as of 1955. G R A N T S - IN - A ID AND
LOCAL
AND
H EA LT H
STATE S E R V IC E »
Although it is sometimes difficult to as sign credit appropriately, the following constructive developments occurred dur ingthe tenyear period subsequent to the real beginningof grants-in-aidtostatesin 1936, the year in which the Social Se curity Act was passed: 1. Per capita state appropriations for health purposes increased for all states, rising from an average of 10/i cents to 26 cents. Total annual appropriations by states increased from $13,258,000 to $33,560,000. Meanwhile the amount of federal grants paid to states rose from about 7% million dollars to'11 million dollars annually. This would indicate that federal grants-in-aid, instead of re tarding, stimulate the financial participa tion of state governments in health activities. The increasedfunds fromboth sources have been used to support the state health department structure and the activities conducted by state per sonnel. In addition, they provided finan cial assistance to local health units, labo ratories, and special health projects operated by counties, cities, and other political subdivisions. Duringthetenyear period, local appropriations for health purposes increased from22^2 to 59 mil
SEVENTH N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E . . . V O L U M E 54, FEBR U A RY 1957 • 185
lion dollars. The estimated expenditures from all sources by state health depart ments for dental activities underwent a concurrent rise from $37,000 in 1930 to $708,000 in 1946. 2. In the period 1940 to 1946, full time personnel employed by state health departments increased from 10,128 to 12,414, an increase of 23 per cent. The number of full-time dentists, ontheother hand, fell from124 to 79, probably asthe result of war-relatedhandicaps inobtain ing personnel. However, although the number of dentists decreased by one third, the funds expended for dental public health purposes increased almost twentyfold over expenditures in 1930. One possible explanation for this seem ing inconsistency might be the growth during this period of local dental public health programs which absorbed funds fromstate and local sources without re quiring additional state personnel. 3. There were only 18 state health departments with identifiable dental projects in 1935. Despite the prevalent shortage of dental personnel, thenumber increased to 35 by 1940 and to 39 by 1946. (At the present time all states but one, Arizona, have provision for state dental public health programs.) These stateprograms conductededucational ac tivities, promoted and organized local dental programs, and provided dental consultation service to local health de partments as well as to private dentists, dental hygienists, physicians, nurses, and others. Many states conducted surveys of selected population groups to determine the influence of certain factors on dental health. In a few instances, by financial assistance or by furnishing personnel, they provided special dental services to limitedgroups inthe population. G R A N T - IN - A ID AND
toits administration are embodied inthe Act, setsforththebasisfor administrative relationships between the governmental agencies involved. The consultant rela tionships resulting from this administra tive requirement are concerned chiefly withplans, fieldservices, andrecords and reports. These items constitute the basis for the establishment and conduct of the consultant services developed by the federal government for administering grants-in-aid. The legislative provision requiring re viewof plans bythe granting agency has some obvious advantages. One of these is the assurance of some degree of uni formityinprogramoperation. Again, the quality of service is improved by the op portunity to exchange ideas and benefit from a broad range of experience and understanding. Field services offer an opportunity for stimulation and encouragement on a col laborative basis in dealing with problem areas in the dental program. The records and reports required by the granting agency offer an excellent means for joint consideration of the effectiveness of the program conducted by the recipient of the grant. In this re gard, recent developments indental pro gramanalysis indicate that the process of programevaluation is almost inseparable fromprogramplanning, once a program is under way. The basic document re quired of the states by the Public Health Service is termed the “State Public HealthPlan”; however, amoreobjective, but unofficial, type of record for setting forth the state dental program plan has been developed during recent years.7 This plan record, although not required, has the advantage of incorporating pro cedures for programevaluation and is in use in many of the states.
A D M IN IS T R A T IO N
F E D E R A L C O N S U L T A T IO N
The legislativeactioncreatingagrant-inaid, by the fact that conditions essential
7. Knutson, J . W . A c c o m p lis h m e n ts th a t may be achie ved and m ethods o f e v a lu a tin g local p u b lic health d e n ta l p ro g ra m s . A m .A . Pub. H e a lth Den. Bui. 13:1 Feb. 1953.
186 • THE J O U R N A L O F T H E A M E R IC A N D EN T A L A S S O C IA T IO N
their usein combatting the dental health problem; and cooperate with state and local health, education, and other activi Consequent to the utilization of federal ties in the conduct of projects in dental grant-in-aid funds in state dental pro public health. grams, the federal government provides technical andconsultant dental personnel N O N D E N T A L G R A N T - IN - A ID F U N D S to carry out its function in the adminis AND DEN TAL PROGRAM S trationof the grant funds. The principal structure through which There are a wide variety of federal these responsibilities are conducted at grants-in-aid for health purposes. Al thefederal level iscomposedof thedental though none of these grants provide advisory services of the Children’s specifically for dental activities, the ob Bureau, and the Bureauof State Services jectives of several are sufficiently broad andits Divisionof Dental Public Health, to permit use of their funds for dental where dental public health activities are programs in the states. centralized within the Public Health Under provisions of the maternal and Service. Regional offices constitute ex child health grants-in-aid, a large num tensions of the Bureau which maintain berof statedental publichealthprograms intimate functional relations with the have been established since 1935. At the states. Consultant dental personnel, under present time, 41 state dental programs the technical supervision of the Division utilizethesefunds, amountingtoapproxi of Dental PublicHealth, staff theregional mately$800,000 annually, for administra offices and maintain working relations tion and operation. withtheircounterparts inthestatehealth Cancer control grant funds allotted to departments. statehealthdepartments are usedto con These consultant personnel are re duct institutes and seminars on oral can sponsible for the conduct of functions cerforpracticingdentists, andtoproduce related to the administration of grant and distribute literature on oral cancer. funds of the Public Health Service, In The Assistance to States General addition, theyact as technical consultants grants-in-aid of the Public Health Serv to the nondental regional representatives ice is used to the extent of about of the Children’s Bureau. They serve also $100,000 annually for basic services in as consultants at the regional level to the seven state dental programs. construction grant program of the Di The total expenditure for state dental vision of Hospital and Medical Facili programs budgeted for the 1954-5 fiscal ties of the Bureau of Medical Services, year was $2,133,443. Of this amount, ap Public Health Service, and to other proximately 42 per cent came from regional consultant personnel. grant-in-aid programs administered by Unrelated to grant administration the Public Health Service and the Chil functions, but carried out as a function dren’s Bureau. derived frombasic Public Health Service legislation,8 the regional dental con IN A D E Q U A C IE S O F N O N D E N T A L sultants, both independently and in co G R A N T S - IN - A ID operation with state and local dental program personnel, conduct investiga Because of the lackof earmarked federal tions of the extent and nature of general grant funds, state dental programs have and specific dental problems. They de termine resources available for dental 8. The P u blic H e a lth Service A c t (58 S tat. 682, 42 public health application and encourage USC 201 et. s e q .): as a m ende d. RO LE OF FEDERAL
D EN TAL
C O N SU LTAN TS
SEVENTH N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E . . . V O L U M E 54, FEBR U A RY 1957 • 187
had to rely mainly on other federal cate gorical grants with dental-related aspects for funds tosupplement thefiscal support of state appropriations. Although, in some states, there is an earmarked state appropriation for the dental program, state appropriations for general health purposes create a situation in which the dental program must compete on un favorable terms with other health activi ties for a share of limited state health funds. Frequently the noncategoricail general assistance grant funds are exhausted by the basic administrative and programre quirements of the state health depart ment, leavinglittleornoneforthosecate gorical health programs which possess no specific grant funds. This inadequacy in financial support results in serious re striction in the scope and emphasis of state dental program activities. The skeletal staffs which exist in many state dental programs are unable to devote morethanlipservicetothedental aspects of chronic illness, dental problems of the aging, topical fluoride programs and the promotionof fluoridation. Also, technical competence at the state level should be available to aid communities in the de velopment of local dental programs. With few exceptions, understaffed state dental programs are unable to provide this assistance. Furthermore, state pro grams to a large extent are not able to make essential, basic, comprehensive studies of the nature and extent of their dental health problems, from which to develop methods for the prevention and control of dental diseases. Exceptions to the foregoing do exist in such states as Tennessee and Michigan, where sizable appropriations of state funds augment funds available from grant sources. In these states the range and extent of dental public health activi ties have been substantially increased by the addition of dental personnel to the state staff. All-in-all, the lack of adequate funds
is a major deterrent to development of statedental programs. The small fraction of total health funds available fromcur rent sources for dental public healthpro grams clearlyindicates thepotential value of a categorical dental grant in stimulat inggrowthof dental activities at thestate and community levels. U S E O F C A T E G O R IC A L D E N T A L G R A N T S - IN - A ID
It is expected that a special grant-in-aid appropriation for dental health purposes would be used by the states to support and strengthen such basic dental public health services as: 1. Training of dental division staff members and private dentists who par ticipate in the dental public health pro gram. 2. Health education programs and studies of methods tomakemore effective the interpretation of the benefits of good dental health to the public. 3. Establishment and maintenance of community dental service clinics. 4. Promotional programs designed to interest communities in the application of effective methods and procedures for thecontrol of dental diseases. 5. Addition of personnel for the con duct of topical fluoride programs inrural areas. 6. Provision of expert consultation and guidance to local dental programs in utilizing effective technical and ad ministrative procedures. 7. Specific research studies such as those directed toward investigation of epidemiological characteristics of dental disease or in administrative research di rectedtoward the solutionof operational problems. 8. In-service trainingfor state or local personnel. 9. Utilization of undergraduate den tal students in program operations as a recruitment device, to expand their in terest in dental public health work, and
188 • T H E J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
increase the number of dental public considerations focus on plans, field serv ices, and records and reports. The health workers. 10. Technical guidance andassistanceperformanceof theseadministrativefunc to teacher training schools in strengthen tions by the federal government consti tutes the basis for the establishment and ing dental phases of health teaching. More extensive utilization of grant-in- conduct of consultant services to states. aid funds for dental program purposes Regional dental consultants and their wouldpermit theadditionof dentists and staffs fulfill this responsibility in the other professional persons to the staffs of regional office of the PublicHealth Serv state and local health departments to ice, affording opportunities for working meet the demandfor services where such relationships with state and local dental demand already exists, or to stimulate personnel injoint considerationof dental interest in dental activities where none public health programs. Because of this exists. At the present time, no other administratively derived relationship, the means for providing adequate, essential conduct of dental public healthprograms becomes a working partnership of the community support seems available. three units of governmental health serv ice. SU M M A R Y State and local dental public health The federal grant-in-aid system is a programs are dependent for financial method devised for the purpose of support, fromother than state and local equalizing, between the poorer and the sources, on several nondental grants-inmore wealthystates, the burden of finan aid. Justificationforobtainingfundsfrom cial support for state and local govern thesegrant sources isbased onthe dental mental health services. This procedure aspects of the health problemfor which provides proportionately more assistance the grant was appropriated. The inade to the poorer states where fiscal resources quacy of funds fromthese sources is evi are inadequate. In so doing, the grants dent, andpoints tothe needfor increased systemhas been effective in stimulating dental programfundsfromgrant sources. the establishment of new health pro There are many constructive purposes grams, expansion and improvement of towhich additional grant funds could be existing programs, raising standards of devoted. operation, and in securing and training From the foregoing observations it competent personnel. should be apparent that grant-in-aid Funds are allotted to the states in the funds are anessential factor inproviding form of grants, and are then reallotted financial assistance to states for the pur to local health agencies or expended in poseof stimulatingthe establishment and direct state services. Matching funds conduct of public health programs, and fromstate and local sources are required for stimulating increased state and local to obtaingrant funds. appropriations for health purposes. Al The granting agency influences the though dental public health programs grant program by requiring that the have shared in this process, and have grant recipient adopt certain minimum undergone a degree of development and standards for program administration expansion since the general application and operation and spend the funds for of the grant principle was initiated in the purposes for which they were ap 1935, there is considerable room for propriated. Inthefunctioningof federal- additional progress and improvement in state relationships derived from the this area of federal, state, and local rela administration of grant-in-aid funds, tionships.