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Planning Councils of the four Councils of Covernment (COGS).19 The competing application resulted from the union of various dissatisfied factions which together created a consumer association to sponsor their application. The COGS had created the HSA, which now proposed to contract 30% of its total budget to the COGS for "services." Although the agency made some minor budget modifications, the contract remains in force.

Roberto Tijerina, director of South Texas Family Planning and member of the HSA of South Texas board (the competing group which lost its bid to be the HSA), objected to the composition of the HSA's governing board. In a letter to Texas Governor Dolph Briscoe, he pointed out that two planning regions covering nineteen counties had inadequate minority representation on the board. The two areas had a total of fifteen board members but none was either a MexicanAmerican provider or a black provider. Only two of the fifteen were Mexican-Americans. There was virtually no representation for the low-income and elderly of the area. Olga Gonzales, a COG member, stated, "When they were setting up their [HSA] board, they weren't interested in getting consumer representation. I really feel our COG did not make an honest effort to involve consumers and low-income people. . .There aren't any real consumers on the board now. . .There aren't any poor on the board. "20

The battle between the two competing groups for designation has left much ill will and a polarized community. It has weakened the HSA's ability to provide effective health planning. It has also delayed the organization and work of the agency. An early application of the COG group eventually designated as the HSA was rejected by HEW because it did not document consumer involvement in the development of its agency. There was, in fact, little such involvement to document. Nor has the situation changed since the HSA's designation. Unless an active effort is made to include members of the competing consumer association and other interested consumers on the HSA board, it is unlikely that the agency will ever get the kind of public support it requires to operate effectively.

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WEST TENNESSEE HEALTH IMPROVEMENT ASSOCIATION

The West Tennessee Health Improvement Association, located in Jackson, evolved from a CHP agency that was unique in that it received no HEW money. James Freeman, director of project review for the HSA, described the parent organization as "the pet project of the Regional Medical Program." Those associated with the agency considered it to be one of the most effective. When they moved to the new agency, operating and planning procedures were, in effect, carried over to that organization.21

There are fifty-one members of the Association's board of directors. According to one staff member, most of the twenty-five providers got involved in the HSA because "they saw it as a potential threat."22 The consumer members range in occupations from teachers to county judges. It took HEW pressure for the agency to increase the number of minority representatives. They now make up roughly 13% of the total membership. Efforts have also been made to include low-income members on the board. According to Jim Freeman, the Assistant Director, the agency had difficulty deciding how to select low-income people as prospective members. The staff requested that organizations which represent poor people submit nominations. The nominees, in effect, were people who represented low-income people, not low-income people themselves. By selecting representatives of low-income people, the Association was following a practice that is common among HSAS in the southern states, where a strong bias exists in many agencies against having low-income people on the boards.

The West Tennessee Health Systems Agency has been more successful in involving the general public in its work than it has been in involving the poor. Board and committee meetings are publicized via public service spots on television and radio, and through local newspapers. The local newspaper has cooperated in providing publicity and in covering the HSA's activities. As a result, the general public is aware of the agency's work and committee meetings and board meetings every other month. In May, 1976, a vote for quarterly board meetings passed by a narrow margin. Any decisions which have

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to be made between meetings are now made by the executive committee which has nineteen members and includes four females and one black, Several members expressed fear that the executive committee might become too powerful and destroy what they had accomplished to date, Others simply felt that the full board should not pass off its duties to the executive committee. If it does, it seems certain that the agency will lose some of the public support it now enjoys. As it now operates, the West Tennessee Health Improvement Association is ar example of an agency where consumers, some providers, and the genera. 23 public are working together in a spirit of cooperation."

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PROVIDER INFLUENCE

WEST ARKANSAS HEALTH SYSTEMS AGENCY

The West Arkansas Health Systems Agency, located in Hot Springs, evolved from three CHP agencies. Most of its professional staff was affiliated with the previous program. They brought experience and skill to the new agency, but they also brought a strong bias that health planning should be left to the "experts." Consequently, they made little effort to include the community in the early phases of their work. The agency attempted to recruit people who were already active in their communities and had some interest in and knowledge of health care. It took the view that only individuals who were familiar with health care problems could serve effectively on the board. Low income persons are unrepresented and females are seriously under-represented. The thirty-member board contains only five women, one of whom is black.

As noted, the consumer members of the West Arkansas Health Systems Agency are relatively well-informed about health planning. Largely for this reason, the director and staff have made no effort to set up special training sessions for them. Despite their relative sophistication, some consumer board members still fear that the providers will control the agency and use it to protect their own interests. For example, some of the doctors oppose placing any limitations on health facility construction and services. However, other interested groups, particularly mental health officials and individuals associated with the Arkansas Community Organizations for Reform Now (ACORN) have a strong interest in the HSA and may be able to counter some of the influence enjoyed by the providers and the 24 professional health groups.

NORTH CENTRAL GEORGIA HEALTH SYSTEMS AGENCY

The North Central Georgia HSA grew out of the state's Regional Medical Program. The board is largely dominated by providers, many of whom worked with the previous program, and the director, Robert Youngerman, an attorney who formerly worked with the Georgia Regional

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Medical Planning Commission. The consumer members tend to be deferential towards, if not intimidated by, the providers--particularly the doctors. One board member admitted that the HSA's biggest problem is that the board is "provider-oriented."25

In October, 1976, the issue of public involvement in the agency arose when several organizations requested that the board provide information about how it would set goals, determine priorities, and establish procedures. The president of the board said that the questions would be answered in the planning committee's report, which was to be presented later in the meeting. A representative of the groups that requested the information asked for a commitment from the board to publicize broadly the board hearings. He also asked to be allowed to comment on the planning committee's report. The president stated that to do so would "violate established procedures." The board then voted overwhelmingly to follow the agenda and end discussion. However, the chairman of the planning committee requested that comment be allowed after the report; several individuals protested the initial ruling that cut off discussion. result, the president finally yielded to pressure and allowed the group's spokesman to comment on the report. This incident reveals clearly that officials of the agency resist public involvement instead of encouraging it.26

As a

The HSA director and staff failed to publicize adequately this meeting, and consequently, attendance by the general public was low. One board member said a letter had been sent to the local When newspaper, but it chose not to print notice of the meeting. contacted, the editor said no explanation of the importance of the meeting was given; if it had been given, he said he would have printed the notice on the front page. The agency's executive director did not consider public involvement to be a major consideration. His approach to the issue was to do no more than required by law to open his agency to public participation and scrutiny.27

Because of the North Central Georgia HSA's resistance to public involvement, and its questionable means of selecting board members,