The policies developed by the Department for carrying out the intent of Section 1534 are significant to a basic understanding of the way the Centers program has evolved. The Department decided that the program should support one Center in each of HEW's ten regions. A competitive procurement for establishment of technical assistance centers was undertaken in late 1975. On the basis of the initial procurement, five contracts were negotiated and Centers were established in HEW Regions I, II, III, IV, and VI on January 1, 1976. A second procurement in the spring of 1976 led to the establishment of Centers in the remaining five regions on July 1, 1976. The auspices and locations of the ten Centers for Health Planning appear in Figure I:

Despite the fact that all ten Centers were developed on the basis of essentially the same set of contract specifications, there is wide variation in some aspects of their organization. Two of the Centers are university-based, two are based in consortia of universities, and six are private non-profit corporations. Internal organization also varies from Center to Center, with some Centers organizing their staff on a geographic basis while others organize according to a functional classification of Center tasks.

Under terms of the contract, each Center was required to establish a Advisory Board representative of the client agencies and states within the region it serves. The Advisory Board is intended to provide the Center with client agency perceptions of needs and priorities, of appropriate means to meet those needs, and feedback to assist the center in evaluating its activities and making necessary adjustments.

The Advisory Board provides a direct communications link between the Center and its various client agencies in the field. The Board can indicate proper directions for content of both training courses and consultations. The Board can convey reactions from the field to various Center activities. The average size of the Advisory Board is twelve members, with a range from nine to 15. Of the 120 individuals who serve on the Advisory Boards of the ten Centers, 41 (34%) are staff of health systems agencies, 33 (27.5%) are staff members of state health planning and development agencies, and 42 (35%) are members of HSA boards or statewide health coordinating councils or both. The remaining four individuals who serve on center advisory boards are representatives of institutions or organizations cooperating in the Center's activities. Ninety-five (79%) of the members of the Advisory Boards are male and 25 (21%) are female. Ten percent of the individuals serving in this capacity are members of minority groups.

HOW CENTERS OPERATE

Some understanding of how the Centers operate in provision of technical assistance to the client agencies is necessary to a thorough understanding of this program. As was indicated earlier, the Centers are funded under cost-reimbursement contracts from the Department. The contract sets a minimum number of courses and person-years of consultation which must be provided over a two year period. These activity levels reflect regional variations in the number of client agencies.

Each training course, major consultation, and major generic document must be approved in advance by a Regional Project Officer in the Regional Office of HEW for the region served by the Center. The Center prepares a task order covering each major activity and submits to the Regional Office. task orders are also forwarded to the Central Office of the program for information and for comments.

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The existence of the task order mechanism means that the activity levels reflected in this report and the emphasis on various performance standards categories in the training and technical assistance programs of the Centers have been approved by the Federal government on a case-by-case basis and reflect a federal perception of the importance of the specific activity within a region.

Another aspect of Center operations which is established under the contract is evaluation of technical assistance activities. Each major activity is subject to a post-evaluation following a protocol developed by the Center--in accord with provisions of the contract--and approved by the Regional Project Officer. These evaluations are provided to the Regional Project Officer and Central Office Associate Project Officer following each major technical assistance activity. Thus the Department is deeply involved in the programming of an individual Center through the review and approval/disapproval of task orders, and has evaluative materials relating to the Center available on a continuing basis.

HOW CENTERS ARE STAFFED

Just as organization of the Centers varies from region to region, so does staffing. The size of a Center staff is affected by two variables--the size of the region and the Center's approach to providing its services. The ten Centers have a total of 86 full-time staff and an additional 12 part-time staff. Sixty-seven of the staff members are classified as professional staff and the remainder as support staff. Of the Centers' professional staff, 23% have doctorates, and 48% have master degrees in health planning or related fields.

The staff members of the ten Centers for Health Planning come from a variety of backgrounds. Forty-two percent of the staff members bring experience with areawide comprehensive health planning agencies to the Center. Eighteen percent have previously worked with state health planning agencies and 15% with Regional Medical Programs. Sixteen percent have experience working in health institutions and 15% with consulting organizations. In the educational field, 31% have experience in graduate level university teaching and 24% in the teaching of undergraduate courses in universities and colleges.

The Congress was concerned that the staff of a Center represent a variety of disciplines. A review of the specialties of staff members in the ten Centers for Health Planning shows that the most common specialties are health planning, agency management, data and statistics, health economics, and education. Other areas heavily represented in Center staffing include community organization and development, mental health planning, and public relations. Each of the ten Centers have at least six of these eight specialties represented on staff. In addition, more than a dozen other specialties, such as urban planning, survey research, policy analysis and capital finance, are present on staff in one or more of the ten Centers.

CONSULTANT USE BY CENTERS

One of the strengths of the independent Center approach is the relative freedom accorded such Centers in identifying and utilizing consultants other than Center staff. Consultants are used as faculty for training courses, to prepare background materials and generic documents, and for direct consultative services with client agencies. The ten Centers have made extensive use of such outside consultants in carrying out their program of activities. During the period covered in this report, 823 consultants were utilized by the ten Centers, 50% as training faculty and the remainder in direct consultation and preparation of generic materials.

The use of outside consultants provides a Center with an opportunity to tap a variety of potential resources both within its region and from other parts of the country. The relative freedom accorded an independent Center in seeking out consultative assistance is indicated in the background of the consultants utilized by the ten Centers during this reporting period. Nearly three quarters of the consultants used were drawn from three categories of individuals--university faculty members, staff members of HSAs/ SHPDAS, and free-lance professional consultants. During the period covered by this report, the ten Centers' major source of consultative assistance were university faculty members (26%) and HSA/SHPDA staff (26%). Free-lance consultants (18%) and commercial consulting firms (11%) constituted the third and fourth largest group, with the remainder of the consultants being drawn from the other categories.

THE TRAINING MISSION

Under the contract for services from the Department, each Center is required to carry out a minimum number of training courses directed at various target audiences within their client group each year. Each course is designed by, or for, the Center, and is based on perceptions of client agency needs gained from the Advisory Board, from surveys of client agencies, and from other ongoing contacts between the Center and the client agencies. The Center's training activities are tailored to the special needs and circumstances of a variety of audiences. Usually, courses are targeted to specific components of the client agency audience, such as HSA staff, consumer board members, SHPDA staff, or SHCC members. Other courses are broader in their orientation and touch on the interests of more than one of these groups.

Each Center offers courses in a variety of locations throughout its region. It is characteristic of the Centers program to decentralize training activities to bring them closer to the various client groups served.

Each Center is responsible for developing a curriculum, preparing materials, and securing faculty for its course offerings. The Center also manages the course, providing for registration, housing, and evaluation.

The Centers use a wide variety of training techniques in carrying out their responsibilities. The particular approach used in a given training course varies with the audience, the objectives of the course, and the subject matter being covered. Centers use traditional lecture/discussion approaches, workshops, seminars, retreats, and similations in bringing the latest policy and technical information concerning health planning to the client agencies.

During the two year period from January 1, 1976 through December 31, 1977, the ten Centers presented a total of 241 training courses for their client agencies. The training courses varied in length from one to four days. The number of attendees at a single course varied from six individuals for a small intensive seminar to 190 attendees at a large lecture/discussion course. During the same period, a total 8,469 participants were trained, an average of 35 participants per course. Of the total participants, 3,955 (46.7%) were HSA staff members, 2,004 (23.7%) were HSA board members, 1,008 (11.9%) were state agency staff, and 412 (4.9%) were classified as SHCC members. An additional 1,090 attendees, representing 12.8% of the total, were classified as "other". SHCC attendance appears low. It is important to remember, however, that many people who classified themselves as HSA board members at the time of registration in the course are also members of a SHCC. The SHCC attendance figure represents, for the most part, attendance at specific SHCC-oriented courses presented by various centers. Attendance data by category of attendee is summarized in Table I on page 8.

The courses presented by the Centers were also analyzed according to the seven performance standard categories established by the Department for HSAS and SHPDAS. These performance standard categories are set out as expectations on the part of the Department of a satisfactorily operating health planning and development agency. A given 'course offering from a center may deal with more than one of the categories of performance standard. Table II on page 9 summarizes the training experience of the ten centers during the reporting period from the perspective of the performance standards covered. As might be expected during a period when the planning and development agencies were beginning their programs, and developing their initial health systems plans and annual implementation plans, the most common course content was in the area of plan development (48.5% of courses). The second most common area, plan implementation/review (36.9%) reflects the high priority placed on project review activities, with their potential for cost containment. The third most common area was agency organization and management (33.6%), an area of particular interest to the health planning and development agencies during the start-up phase of their activities.

The variation in emphasis from region to region points up the variation in client agency needs, as identified through the Advisory Board and client contacts, and as accepted by the Regional Office through approval of task orders for the courses.