A. Values of the policy (should statements and assumptions). What value premises or ideological assumptions underlie the policy approach?
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) values the nutritional health of women, infants, and children. WIC values nutrition and education. The program provides women, infants, and children with nutritious foods in hopes of improving the health of ‘at-risk’ families. The program also provides women with the opportunity to receive education on healthy eating styles.
“Value Enhanced Nutrition Assessment is part of WIC’s initiative to revitalize nutrition services. This initiative standardizes a process for completing a comprehensive nutrition assessment. It expands the purpose of nutrition assessment from eligibility determination to improved nutrition education. Value Enhanced Nutrition Assessment improves the risk assessment process by ensuring that a medical-nutritional assessment is completed along with a streamlined dietary assessment for collecting information for individualized nutrition services.” (Washington State WIC Nutrition Program, 2010, para. 1)
B. Goals, both manifest and latent
Two of WIC’s manifest goals are: “1)To provide ongoing health services free or at reduced cost to residents of areas or members of populations in which substantial numbers of women, infants and children are at nutritional risk; and 2)To provide health screening, certification, food prescription, and nutrition counseling.” (Supplemental Nutrition Program for Women, Infants, and Children, para. 6)
“The mission of the WIC program is to improve the health status of women, infants, and children; to reduce the incidence of infant mortality, premature births and low birth weight; and to aid in the development of children.” (Supplemental Nutrition Program for Women, Infants, and Children, para. 1)
“Six of the ten leading causes of death in the United States are linked to a poor diet. The New York State Department of Health Division of Nutrition’s goal is to improve the health of New Yorkers through prevention, providing nutritious foods and educating people about making smart nutrition choices.” (Nutrition, 2010, para. 1)
“Providing good nutrition for low-income pregnant, breastfeeding, and postpartum women, infants, and preschool children; school-age children in high-risk areas; people in need of emergency food assistance; adults at risk for chronic disease; persons with AIDS; the frail elderly and children up to age 18 and the functionally impaired adults that are in day care are the main focus of the Division of Nutrition.” (Nutrition, 2010, para. 2)
“The Division of Nutrition has many programs in place to help achieve these goals and to reach as many people that qualify for these programs, as possible.” (Nutrition, 2010, para. 1)
Several of WIC’s latent goals are: “1)Serve only residents of [the particular state], and within the geographic area defined by local agency procedure if applicable, or who are members of a designated population with a common special need, including but not limited to homeless, migrant or Native American persons, as defined in the WIC Policy and Procedures Manual; 2)Provide safeguards against agency, vendor or participant abuse of WIC program funds or services; 3)Integrate/coordinate services with the Family Case Management (FCM) program serving the provider WIC recipients to achieve the goal of 95% of WIC pregnant women and infants active in the FCM program; 4)Providers will make reasonable efforts to assure that WIC enrolled infants and children are appropriately immunized. Reasonable efforts may include recording WIC recipient immunization status into Cornerstone, providing immunization on site or by referral, and follow-up of immunization compliance at subsequent visits; 5)The Provider will make reasonable efforts to assure Medicaid/insurance status of all WIC recipients; 6)The Provider agrees to comply with requirements in accordance with Federal and State laws and regulations, U.S. Department of Agriculture Code of Regulations (7 CFR 246), FNS Instructions and Policies, (including FNS Instruction 113, Civil Rights Compliance and Enforcement), National Voter Registration Act (NVRA) of 1993 (Public Law 103-31; 42 USC 1973 gg) and the State WIC Policy and Procedure Manual. Staff must receive WIC training annually, appropriate to their job duties, including health, nutrition, counseling and federal program requirements; 7)The Program applicant hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Title IX of the Education Amendments of 1972 (20 U.S.C.1681 et seq.) Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.794), Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.); all provisions required by the implementing regulations of the Department of Agriculture; Department of Justice Enforcement Guidelines, 28 CFR 50.3 and 42; and FNS directives and guidelines, to the effect that, no person shall, on the ground of race, color, national origin, sex, age or handicap, be excluded from participation in, be denied benefits of, or otherwise be subject to discrimination under any program or activity for which the Program applicant receives Federal financial assistance from FNS; and hereby gives assurance that it will immediately take measures necessary to effectuate this agreement. By accepting this assurance, the Program applicant agrees to compile data, maintain records and submit reports as required, to permit effective enforcement of the nondiscrimination laws and permit authorized USDA personnel during normal working hours to review such records, books and accounts as needed to ascertain compliance with the nondiscrimination laws. If there are any violations of this assurance, the Department of Agriculture, Food and Nutrition Service, shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Program applicant, its successors, transferees and assignees, as long as it receives assistance or retains possession of any assistance from the Department. The person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Program applicant; 8)The Provider must conduct a self-monitoring evaluation of its operations annually to ensure compliance with WIC Federal and State Regulations and state policies. Provider tools used for self-monitoring must be the State WIC Management Evaluation tool or other state approved tool. The Provider must maintain a file of completed self-monitoring evaluation forms for review by state or federal staff; AND 9)Agencies participating in the Farmers’ Market Nutrition Program will provide training, oversight and monitoring of farmers in participating Farmer’s Markets.” (Supplemental Nutrition Program for Women, Infants, and Children, para. 6)
1. Has the policy achieved these goals?
“The WIC program has been deemed a success because it has achieved its initial goals, and because other beneficial outcomes have been identified. The initial goals of increasing length of pregnancies, decreasing early births and low birth weights, increasing use of prenatal care and decreasing the incidence of iron-deficiency anemia in infants and children have all been achieved. This is partially due to a higher intake of ten nutrients, including the targeted nutrients iron and vitamin C. Increased rates of breastfeeding, as well as improved growth rates, have also been attributed to the WIC program. WIC program enrollment has also significantly improved the nutritional status of pregnant women. Unexpected benefits include a savings in health care costs from $1.77 to $3.13 for each dollar spent on WIC. Further, in terms of school achievement, WIC children have improved vocabulary scores and memory of numbers.” (WIC Program, 2010, para. 8)
“Due to the success of the program, other issues that affect this population have been added to the services of WIC clinic visits. Participant screening now includes issues such as dental care; lead screening; physical, sexual, or verbal abuse; alcohol, drug, and tobacco use; voter registration; immunizations; and family reading practices. This “melting pot” of health and education initiatives has placed the WIC program in a position of being an important partner in promoting the health and nutritional status of mothers and children.” (WIC Program, 2010, para. 9)
2. Why or why not?
“The concept of nutrition risk assessment is integral to the design and operation of the WIC program. Nutrition risk is a criterion for program eligibility, and nutrition risk criteria are used to assign a priority level to women, infants, and children. By serving those at the highest priority levels first, the WIC priority system is used to allocate limited program resources among eligible individuals. In addition, the nutrition risk assessments are used to tailor the WIC intervention and, in some cases, to monitor the health and nutrition status of program participants.” (WIC Nutrition Risk Criteria, 1996, p. 335)
“The framework that was used in the scientific assessment conducted for this report has two key features. The first is the exposition and utilization of the concept of potential to benefit from the delivery of interventions and services provided by the WIC program. This concept differs from the approach that has guided the development of risk criteria used by the WIC program, namely, assessment of the individual’s risk of a poor outcome. This application of the concept of potential to benefit moves the program focus from curative (tertiary prevention) to risk reduction (secondary prevention). Utilizing such an approach can provide for more efficient targeting of the scarce resources available to the WIC program and also improve outcomes.” (WIC Nutrition Risk Criteria, 1996, p. 335)
“A second important feature of the analytical framework is the explicit consideration of the concepts of yield of risk, yield of benefit, and sensitivity of the nutrition risk criteria used by the WIC program. These concepts, in conjunction with the concepts of indicators of risk and indicators of benefit, have implications that underlie both the assessments of the nutrition risk criteria used by the WIC program and the development of the report’s conclusions and recommendations. In particular, risk indicators and cutoff points should be chosen such that the highest proportion of those who are truly at risk can be identified and the highest proportion of those identified can benefit from WIC program participation. With limited program resources, cutoff points should be set with less than perfect sensitivity to increase yield, recognizing that as cutoff points become more restrictive, some individuals who could benefit from WIC services will not be served.” (WIC Nutrition Risk Criteria, 1996, p. 335-336)
a. Are the goals just and democratic?
“Income guidelines have been expanded to allow more Callaway County residents to participate in the nutrition program for Women, Infants and Children (WIC), says Sharon Lynch, director of the Callaway County Health Department.” (Norfleet, 2010, para. 1)
“This should mean an even larger increase in the number of families we are serving with the program. We have noticed in the last few months there has been a gradual increase in the number of women participating in the program, Lynch said.” (Norfleet, 2010, para. 2)
“Earlier last year, many Callaway County mothers received the infant formula and then left the program. But more and more of them now are staying in the program longer, Lynch said.” (Norfleet, 2010, para. 3)
“Callaway County women who are wondering if they are eligible should contact our department at 642-6881. We will discuss the program with them and make a health assessment by appointment on Tuesdays and Thursdays of each week, Lynch said.” (Norfleet, 2010, para. 4)
“The new income guidelines were established by the United States Department of Agriculture, which funds the program.” (Norfleet, 2010, para. 5)
“The program, commonly known as WIC, is not a welfare program. It is administered in Callaway County by the Callaway County Department of Health, not by social service agencies. It is designed to improve the health of low and moderate income families by providing access to nutritious foods and helping to develop healthy habits. The program is provided at no cost to eligible mothers, babies and children.” (Norfleet, 2010, para. 6)
“WIC also provides information about healthy eating, nutrition and breast-feeding. It also refers participants to other health-related services after a health assessment of each applicant, Lynch said.” (Norfleet, 2010, para. 7)
“Anyone receiving Medicaid, food stamps or welfare services is automatically eligible for the WIC program because they already have met income guidelines. For others not receiving these benefits, the program is limited to families with incomes of up to 185 percent of the federal poverty level, which is adjusted annually.” (Norfleet, 2010, para. 8)
“A single mother with three children or a husband and a wife with two children are both considered as a family of four people. A family size of four is eligible for the WIC program if annual household income is not greater than $40,793. Last year annual income limit for a family of this size was $39,220.” (Norfleet, 2010, para. 9)
b. Do the goals contribute to a better quality of life for the target population?
“WIC has a positive impact on key health outcomes. Evaluations provide strong evidence that WIC has a positive impact on: (1) the incidence of low birth weight, and other key birth outcomes, and that these positive effects lead to savings in Medicaid costs and (2) children’s intake of key nutrients and immunization rates.” (Program Assessment, para. 2)
“Available program funds are utilized efficiently to maximize service to eligible participants. Over the last fifteen years the national average WIC food package cost has increased at a rate below the general rate of food inflation.” (Program Assessment, para. 3)
“While WIC is largely meeting its long-term performance goals, challenges remain. As the proportion of children who are overweight or at risk of overweight has grown in both the WIC and non-WIC population, combating childhood obesity remains a challenge.” (Program Assessment, para. 4)
To improve WIC’s impact, the following changes are in place:
>> “Initiating changes to the food package to reflect current nutritional guidelines, promote breastfeeding, and better address the health risks facing WIC population, including childhood obesity.” (Program Assessment, para. 5)
>> “Monitoring State food package costs and cost containment efforts to promote continued cost efficiencies.” (Program Assessment, para. 6)
>> “Promoting efforts to address childhood obesity by supporting special State projects which will build on previously-developed WIC-specific obesity prevention interventions.” (Program Assessment, para. 7)
c. Has the program alleviated the problem? Have there been intended or unintended consequences?
There have been many questions raised about the WIC Program and the services that it provides. Here are some of the concerns: “More than half the infant formula used in the United States is provided to mothers at no cost through the federal government’s Special Supplemental Nutrition Program for Women, Infants, and Children, commonly known as WIC. In 2000, Cynthia Tuttle asked: Why does the WIC program continue to be the largest promoter of formula feeding to low-income women in the United States, in terms of the program’s provision of formula products? The challenge provoked fascinating discussion in the journal, but no clear answer. The question still stands. Several related questions can be raised as well. WIC is intended to serve low-income women, infants, and children who are at nutritional risk. WIC reaches almost half of all US infants. Are that many infants in the US low income or at nutritional risk? WIC provides more than half of the formula that is used in the US, but serves less than half the infants. This means that infants who are WIC clients are more likely to get formula than infants who are not in the WIC program. Why? Infant formula is costly. Why is it that low-income people are more likely to use infant formula than high-income people? Does WIC’s distribution of infant formula encourage low-income people to use it? Should low-income people be encouraged to use it? US policy supposedly is to encourage free market competition. Why is it that just three manufacturers dominate the infant formula market in the US? Why does the US government support this triopoly? Why does the government support this triopoly despite the fact that it increases the cost of formula to those who are not WIC clients? WIC operations are funded in part by large rebates to WIC from the formula companies. These rebates are not treated as charitable contributions. How is giving such large rebates economically sensible for the formula companies? Internationally accepted standards say that advertising for infant formula should be limited. How is it that US government publications themselves carry pictures that highlight specific brands of infant formula? Several branches of the US government promote breastfeeding. WIC itself has a program for promoting breastfeeding. Why then does WIC distribute formula free in massive quantities? Why should WIC provide any formula at all to its clients when it is known to be less healthful for infants than breastfeeding?”
C. Eligibility guidelines
a. Who is included and
b. who is excluded?
“Eligibility in the WIC program is limited to pregnant women, women up to 6 months postpartum who are not breastfeeding, breastfeeding women up to 12 months postpartum, infants up to 1 year of age, and children up to their 5th birthday. To be eligible, family income must fall below 185 percent of the poverty guidelines. Persons who participate in the Food Stamp Program, Medicaid, or Temporary Assistance for Needy Families Program (TANF) automatically meet the income eligibility. WIC recipients must also be individually determined to be at ‘nutritional risk’ by a health professional.” (WIC and the Nutrient Intake of Children, para. 3) The four major types of nutritional risk that are recognized for WIC eligibility are: “ (1) detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements, such as anemia, low maternal weight gain, or inadequate growth in children; (2) nutritionally related medical conditions, such as nutrient deficiency diseases, some specific obstetrical risks, or gestational diabetes; (3) dietary deficiencies that impair or endanger health, such as highly restrictive diets, inadequate diet, or inappropriate infant feeding; and (4) conditions, such as homelessness and migrancy, that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions.” (WIC and the Nutrient Intake of Children, para. 3)
“Nationwide, WIC currently serves about 7.4 million low income, nutritionally at-risk participants with a $3.9 billion budget. In California, 82 local agencies serve about 1.24 million participants at 650 local sites, with a FY 1999 food budget of $515 million. Approximately 23% of the participants are pregnant and post-partum women, 23% are infants and 54% are children ages 1-5.” (California WIC Facts, para. 2)
“Because WIC is not an entitlement program, not all participants can be served. Limited funding prevents millions of low income nutritionally at-risk women, infants and children from receiving program benefits. The Department of Health Services estimates that there are over 1.77 million women, infants and children in need of WIC benefits. Thus some 530,000 participants are shut out of the program due to limited funding.” (California WIC Facts, para. 3)
D. Type of service(s) or benefits
a. What is it?
b. Is it adequate?
“WIC service providers are required to offer participants (or their parent, guardian, or proxy) at least two nutrition education sessions during each certification period, which usually lasts 6 months (USDA 1998c). Education may include counseling on the importance of WIC foods in preventing and overcoming the specific risk conditions identified at the time of certification and the need to select a complete diet from a variety of nutritious WIC and non-WIC foods. WIC recipients also receive referrals to other social services and needed health care, such as immunizations.” (WIC and the Nutrient Intake of Children, para. 5)
“The Special Supplemental Nutrition Program for Women, Infants, and Children – or WIC – provides nutritious foods, nutrition education, and access to health care to low-income pregnant women, new mothers, infants, and children under 5. The monthly WIC food package provides foods chosen to improve nutrition for pregnant women, new mothers, and their infants. Adequate and consistent nutrition is crucial to the health and development of very young children, whose brains and bodies are growing rapidly. WIC increases the number of women receiving prenatal care, reduces the incidence of low birth weight and fetal mortality, reduces anemia, and enhances the nutritional quality of the diet of participants.” (D.C. Hunger Solutions, para. 1)
“In Washington, D.C., officials are working with the District’s WIC agency to implement USDA’s newly modernized WIC food package (the foods obtainable with WIC coupons) in the best possible way for clients. The new rules must be implemented in states and the District by October 2009 and include an expanded set of healthy foods. The new food package may include fruits, vegetables, soy milk, tofu, and whole grains other than whole grain breads. The original categories of milk, cheese, eggs, fruit, juice, cereal, beans/peanut butter, infant formula and (for breast feeding women) tuna and carrots will continue to be a part of the package.” (D.C. Hunger Solutions, para. 2)
E. Delivery of service(s). How?
“Most WIC participants receive checks or vouchers each month that allow them to purchase a monthly food package designed to supplement their diets at authorized foodstores. A few locations use alternative food delivery systems. The WIC food package is not intended to meet the total nutritional needs of the participants, and participants are educated on ways to obtain the balance of the necessary nutrients from other food sources. WIC provides foods that are high in five target nutrients–protein, calcium, iron, and vitamins A and C. These nutrients are frequently lacking in the diets of the program’s target population, which may result in adverse health consequences. The WIC food packages also provide vitamin D, folate, and vitamin B-6 (pyridoxine) (USDA 1991). Local WIC agencies prescribe the types and quantities of supplemental foods appropriate for each participant, based on their age and individual needs and preferences. The food package for children 1 to 5 years old consists of milk or cheese, iron-fortified cereal, 100-percent fruit and/or vegetable juice, eggs, and peanut butter or dry beans/peas (children with special dietary needs may receive a different food package). This food package is expected to reduce the prevalence of iron-deficiency anemia, improve diets, and improve physical and mental growth and development (Institute of Medicine, 1996).” (WIC and the Nutrient Intake of Children, para. 4)
F. How is the program financed? Financing: (Private, public, or combination? Adequate?)
WIC is funded through the federal government. Congress allocates a specific amount of funding each year for WIC’s operations. ”The Food and Nutrition Service provides these funds to WIC state agencies in which they distribute special WIC foods, nutrition counseling and education, and administrative costs. (Caan 1997)” (Manifest and Latent Functions of WIC)
“The average monthly cost of the WIC food package for children in 1996 ranged from $32.45 to $46.20 across regions (USDA 1998c).” (WIC and the Nutrient Intake of Children, para. 4)
For the state of Alabama, the Total Food Grant for fiscal year 2010 was $91,512,629; the Total NSA Grant for fiscal year 2010 was $32,752,900; and the Total Grant for fiscal year 2010 was $124,265,529. (FNS-USDA, Funding and Program Data, 2010, para. 1)
G. Social/economic justice, and equity issues
”The Special Supplemental Nutrition Program forWomen, Infants, and Children (WIC) is designed to improve the health of low-income, nutritionally at-risk infants, children, and pregnant, postpartum, and breastfeeding women by providing supplemental food, nutrition education, and health care referrals.” (WIC and the Nutrient Intake of Children, para. 1)
“The WIC Farmer’s Market Nutrition Program (FMNP) is a small program but a significant program because it acknowledges the role of farmers’ markets in sustaining small farmers and local communities. The Farmers’ Market Nutrition Program (FMNP) is associated with the Special Supplemental Nutrition Program for Women, Infants and Children, popularly known as WIC, which is administered in cooperation with the States by the Food and Nutrition Service (FNS) of USDA. WIC provides supplemental foods, health care referrals and nutrition education at no cost to low-income pregnant, breastfeeding and non-breastfeeding post-partum women, and to infants and children up to 5 years of age, who are found to be at nutritional risk. The WIC FMNP was established by Congress in July 1992. It was created to accomplish two goals:
1.To provide fresh, nutritious, unprepared foods (such as fruits and vegetables) from farmers’ markets to women, infants and children who are nutritionally at risk.
2.To expand the awareness and use of farmers’ markets by consumers. The FMNP is now authorized in the District of Columbia, Guam, and 35 States. In addition, 4 Indian Tribal Organizations administer the Program. During Fiscal Year 2000, about 1.9 million recipients received farmers’ market benefits. Coupons redeemed through the FMNP resulted in approximately $17.5 million during Fiscal Year 2000. During Fiscal Year 1999, just under 1.5 million recipients received farmers’ market benefits. Coupons redeemed through the FMNP resulted in $14 million in revenue to farmers during Fiscal Year 1999. FMNP funds are provided through a legislatively mandated set-aside in the WIC program appropriation. Federal funds support 70 percent of the total cost of the program. States operating the FMNP must match the Federal funds allocated to them by contributing at least 30 percent of the cost of the program, except that, if justified and approved by FNS, Indian State agencies may receive a lower rate, but not less than 10 percent. The matching funds can come from State, local, or private sources. A State agency can also count funds used to support similar farmers’ markets operating in the States in meeting the match requirement. States may issue Farmers’ Market coupons to other groups, such as elderly persons or older children, with the matching funds they provide. For Fiscal Year 2001, $20 million of the federally appropriated WIC funds have been earmarked for FMNP State agencies. For Fiscal Year 2000 and 1999, $15 million of the federally appropriated WIC funds have been earmarked for FMNP State agencies.” (WIC Farmer’s Market Nutrition Act, 1997-2009)
Oliveira, V. & Gundersen, C. WIC and the Nutrient Intake of Children. Economic Research Service/USDA. http://www.ers.usda.gov/publications/fanrr5/fanrr5a.pdf
Manifest and Latent Functions of WIC. http://www.oppapers.com/essays/Manifest-Latent-Functions-Wic/74966
Supplemental Nutrition Program for Women, Infants, and Children. http://www.dhs.state.il.us/page.aspx?item=34322