Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results (review)

A Review of the HHS Family Planning Program published by The Institute of Medicine, edited by Adrienne Stith Butler and Ellen Wright Clayton, is a discussion of the objectives of the Title X Program, its organization, and its challenges in providing comprehensive family planning services.

Enacted by Congress in 1970, Title X is the only federally funded program dedicated to providing comprehensive family planning services. Originally charged with serving low-income men and women, the program has been expanded to include adolescents. Since its inception, Title X has been guided by the premise that effective family planning contributes to better physical health as well as social and economic well being.

The assessment of the Title X Program published in this book was solicited by the Office of Family Planning to the Institute of Medicine. The book begins with an executive summary of the key findings and recommendations. The first two chapters explain the importance of, and need for, family planning services. Chapters Three, Four and Five discuss in detail the goals and accomplishments, management, and outcome data related to Title X.

Title X was designed to reach populations who would otherwise not have access to health care. Services are available to anyone at no or reduced cost. The goals of the program set forth by the Office of Family Planning are: to reduce the numbers of unintended pregnancies, to reduce infertility by controlling Chlamydia infections, and to reduce the rate of cervical cancer by screening through Pap screening. Additionally, the program promotes patient-centered and culturally competent care. The in-depth analysis of this assessment will interest all providers working with the Title X Program or serving similar populations in other capacities.

The majority of the book discusses and suggests improvements to the Title X program. Many of the key recommendations revolve around unclear operational priorities and frequent shifts in program emphasis that often have little scientific basis. The pressure of shifting priorities from the program's central office and an increasing number of services has exaggerated the problems of decreased funding due to inflation. Initially, basic contraceptive care was offered; however there are now 13 required services, including physical examination, genetic information, and referrals. Additionally, technological [End Page 1436-] advances, such as augmented and varied contraceptive options and improved laboratory tests, are also straining the program's budget.

The report also states that the Title X Program suffers due to requirements that do not reflect current evidence and professional best practices. An often-cited example relates to Pap smear requirements: Title X requires a Pap smear within six months of starting birth control regardless of age, while American Congress of Obstetricians and Gynecologists (ACOG) recommends Pap smears only after age 21. Within the Title X Program, little funding is dedicated to research and data analysis. Current data from the program do not provide a complete picture, notably because no longitudinal data have been collected or analyzed. Similarly, the three stated goals of the program are difficult to measure and evaluate. Despite these challenges, the review is able to conclude that the program is successful in making comprehensive family planning services available to an increasingly complex patient population.

Central to the report's critiques, Title X requires expanded funding to match the rising costs of new technology, a growing patient population, inflation, and administrative services. The Central Office funds each of the nine federal Department of Health and Human Services regions based on data from 2004; the regions then divide the funds among individual grantees. There is a lack of transparency due to an unclear formula for distributing funds and a lack of input from grantees into allocation decisions. Many grantees receive other funding for patient care as well. While some of these sources complement Title X...