What Works: Applying What We Already Know About Successful Social Policy

The Clinton administration holds as a core belief that long-term economic prosperity requires an educated work force, which in turn requires investment in children, especially those on the margin. That logic puts a premium on assembling information about "what work" in an area where so many believe that nothing works. In the last decade, extensive evidence has shown that the cycle of disadvantage can be broken through systematic societal action. The evidence come from diverse domains, including:

  • School-based health clinics that reduced the rate of teenage childbearing by more than 50 percent within three years and raised the average age at which youngsters became sexually active;
  • Comprehensive prenatal care and nutrition programs that have reduced the proportion of babies born at low birthweight by a third and the proportion of very low birthweight babies by half;
  • Intensive family support, nurse home-visiting, and child care programs that have resulted in rates of child abuse one-fifth to three-quarters lower than the rates among control groups, significantly fewer children removed from home, and fewer mothers on welfare;
  • Preschool programs that have followed their participants to adulthood and found among them fewer dropouts, fewer delinquents, fewer teenage mothers, and fewer jobless youngsters.

The evidence that there are social programs that have succeeded in changing the odds for children-at-risk has been welcomed--but also greeted with skepticism. Critics generally view the evidence as either misleading or trivial. Some who regard it as misleading contend that a social focus on improving health, education, or family functioning diverts attention from hard economics--the need for income supports, job creation, and reformed economic policies. Some who see the evidence as trivial believe that successful programs are so expensive, complicated, idiosyncratic, or personality-dependent that they will never be duplicated on a large scale; others see the politics of public institutions and systems as so cumbersome that what works will never replace what is.

These criticisms do not stand up against the realities encountered by states, communities, foundations, and human service agencies that are trying to change programs, policies, and systems to improve outcomes for children. Experience from the field suggests two important insights for reform: that economic remedies and social remedies work more effectively together than either would alone, and that the new knowledge about the details of successful programs will provide the basis for system reform that will allow successful programs to flourish.


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COMPLEX PROBLEMS REQUIRE COMPLEX REMEDIES

New research on risk factors shows that the elements involved in school failure, teenage pregnancy, intergenerational poverty, and other "rotten outcomes" are multiple and interactive. Because child poverty is the single most powerful risk factor in accounting for high rates of damaging outcomes, higher family incomes are the single most critical need. Family incomes can be raised through the adoption of expanded earned income tax credits, guaranteed child support payments, strengthened income supports, and through policies that lead to full employment, that make work pay, and that provide job training and supports for the transition from welfare to work. Virtually every other industrialized democracy in the world provides an income floor for its children and young families.

But economic remedies will not be enough. When social capital is depleted, economic supports must be coupled with social supports--good schooling, quality child care, comprehensive health services, safe and supportive communities, and services to strengthen families. It is pointless to pit economic remedies against human investment remedies or to argue whether the availability of jobs is more important than the ability to hold a job. School success and job training won't pay off if there are no jobs, and expanded job opportunities can't be seized by young people who lack skills, motivation, networks, and confidence in themselves and their future.

In short, if large numbers of families are stuck at the bottom, interventions known to be effective should be mobilized. But this kind of pragmatism collides with some dearly held beliefs. It evokes the conflict of decades past between the advocates of large-scale economic solutions and the advocates of "services" solutions. The latter were often regarded as muddle-headed adherents to an individualistic, or Freudian, apolitical ethos. They were faulted from all sides for confusing amelioration with prevention, for blaming (or excusing) individuals for their nonmainstream behavior, for ignoring the systemic aspects of persistent poverty, for seeing the road to self-sufficiency as paved with introspection, or for throwing money at problems.

In my recent travels, I find fewer and fewer sophisticated practitioners or policy people embracing an exclusively economic or services strategy. Experts are recognizing that reformed services and institutions are needed alongside economic measures and "hard" supports like jobs and housing. As the New York City Commission on Homelessness recently found, services can be as important as permanent housing in reducing homelessness.

Decent health services, quality child care, parent support, and good schools are essential components of a comprehensive strategy to improve outcomes among the chronically poor, especially when one takes an intergenerational perspective. A good education is probably the most promising way to prevent the disadvantage associated with low family income from being passed down to the next generation. High skills and an educated work force are also widely agreed to be the key to higher productivity for the nation. William Julius Wilson has pointed out that no serious initiative to improve the work force can ignore the social isolation and family instability that so often impede educational success.

Economic and service strategies interact in many ways. Falling wages among young families have meant that many caring parents are able to do less for their children. The self-discipline, responsibility, and deferral of immediate gratification that many see as crucial for the climb to self-sufficiency are not acquired in isolation. The availability of job training, parent-support centers, and high-quality child care helps parents to gain control of their own lives and in turn improve the chances of school success for their children.


WHAT MAKES PROGRAMS WORK

It turns out that programs that work have common attributes that are strikingly consistent. None of these attributes of effective services is counterintuitive or surprising. What is surprising is that while these attributes recur across many different kinds of helping systems, and while they are supported by theory, research, and frontline experience, most programs lack them.

1. Successful programs are comprehensive, intensive, flexible, and responsive. Sister Mary Paul, who runs a family service agency in Brooklyn, says that no one in her program ever says, "This may be what you need, but helping you get it is not part of my job." Staffs in effective programs have extensive repertoires and extensive community networks. They have the capacity to respond flexibly to concrete needs for help with, say, food or housing or a violent family member, as well as to subtler needs for a listening ear. Many of these programs provide their staffs with a pool of emergency funds, limited in amount but for flexible use at the frontline professional's discretion, say to help a family buy a washing machine, a wheelchair, or repair a car needed to keep a job.

It is the responsiveness of these programs and institutions and their willingness to do whatever it takes that is most striking. They know, for example, that children bring more than academic needs to the classroom and that pregnant women bring more than health needs to their prenatal checkups. They know that parent education classes will have little effect on a mother who was herself abused as a child or whose survival concerns have higher priority.

Professionals who staff centers in depleted neighborhoods have found that advice about parenting rings hollow if they can't help with issues of safety and survival. They can't tell mothers to let their babies crawl on the floor when the mothers know that rat bites and rat poison are a greater danger than delayed motor skills. "Parents need to be able to count on us to help them change the unacceptable circumstances in which they live or to help them get out of [the projects]. After that we can start targeting mother-infant interactions," says Gina McLoughlin, former director of the Center for Successful Child Development in Chicago's Robert Taylor Homes.

Good staff seem to be forever willing, in the words of Mary Jo Bane, assistant secretary-designate of Health and Human Services, to "push the boundaries of their job description," to take on an "extended role" in the lives of the children and families they work with. This does not mean that physicians are expected to do job placement and that teachers should double as psychotherapists. Professionals in successful programs do, however, have the time and skills and mind-sets to pay attention to more than their narrow area of expertise, and they are able to mobilize a response that will be more helpful than a referral slip.

These programs respond to the needs of families at times and places that make sense to the family--often at home, at school, or in neighborhood centers and at odd hours, rather than in distant offices on Wednesday afternoons. Families that are already overwhelmed are not asked to negotiate their way through a maze of fragmented and distant services, each with its own eligibility determinations, waiting times, and application forms.

Staff are able to overcome the barriers of fragmentation by actively collaborating across professional and bureaucratic boundaries. James Comer, the child psychiatrist who has successfully turned around New Haven elementary schools, explains that schools responded to the difficulties they encountered over the last two decades by bringing in "psychiatrists, social workers, psychologists, and special education personnel, each to deal with some part of the problem."

When Dr. Comer first came into the New Haven schools, support personnel were deliberately scheduled so that no two of them would ever be in the same school at the same time; they couldn't have planned together if they had wanted to. "Each specialist was doing his or her little thing, each taking a piece of the kid, with nobody thinking about what the kid needs altogether and who should address what." As part of Dr. Comer's school reform efforts, these specialists today work together with teachers, the principal, and parents to add a child development perspective to all of their activities and to provide a climate that supports learning and high expectations for all. The Rockefeller Foundation is now supporting Dr. Comer's efforts to broaden the reach of his approach.

2. Successful programs deal with children as parts of families and with families as parts of communities. Most successful programs have deep roots in the community. They are not imposed from the outside or "parachuted in" but are carefully integrated with specific local community needs and strengths, so that local communi7ties feel genuine ownership.

Successful programs know that strong families are the key to healthy children. So they work not just with one generation but with two--and often three. They nurture parents so parents can better nurture their children. Successful welfare-to-work programs know that it is dangerous folly to ask mothers to engage in training or work without paying attention to the quality of care for their children.

In the successful health clinic, the clinician treating an infant for recurrent diarrhea sees beyond the patient on the examining table to whether the family needs help getting food stamps or even clean water. The successful school, facing the challenge of higher expectations for what all children need to learn, enlists parents in collaborative efforts to encourage children to study. The sucessful school also offers support to parents who need help with their own lives to be able to help their children. Many schools are joining with family support centers, health and social services, and churches to turn schools into what Patricia Graham, president of the Spencer Foundation, calls a community "outpost of civility and concern."

Children learn best when parents and teachers share similar visions, when there is what Sara Lawrence Lightfoot of the Harvard School of Education calls a "sense of constancy" between home and school. A generation ago, schools didn't have to work as self-consciously at developing that relationship. A sense of constancy is harder to come by these days, and it is harder to come by in the inner city, where informal connections are harder to maintain.

3. Staff in successful programs have the time, skills, and support to build relationships of trust and respect with children and families. They work in settings that allow them to develop trusting personal relationships over time and to provide services respectfully, ungrudgingly, and collaboratively.

Successful programs are not "lean and mean." They establish a climate that is welcoming, continuous, and reliable. They often includes a mental health orientation, and their emphasis on relationships of mutual trust likely makes many other activities effective. Home visitors say that respectful relationships make parent education and other interventions work, especially among low-income people who have despaired of getting help from official agencies.

A careful evaluation of an enhanced prenatal care program in Washington, D.C. found that the most important element that kept women in the program and utilizing health services properly was not the program's cash incentives or even easy access to care; rather it was the "friendly support" of "someone to talk to about pregnancy and other life stresses" that was valued most highly. Smallness of scale at the point of service delivery seems also to be crucial. Large schools, massive outpatient clinics, and large case loads vastly complicate the job of personalizing services.

4. Successful programs have a clear mission, but operate flexibly and evolve over time. Successful programs combine a flexible mode of operation with a clearly articulated sense of mission. They operate in an organizational culture that is outcome-oriented rather than rule-bound; they are inclusive, preventive, and empowering. Managers of these programs have no illusion that they can implement the perfect model program. Several Harvard Kennedy School studies found that leaders of prize-winning public programs manage by "groping along" and allow their programs to continually evolve to maintain their responsiveness to changing individual, family, and community needs.

5. Effective interventions start early and have a preventive orientation. The antecedents of rotten outcomes occur early, when it is most effective and economical to intervene. When Isaac Fulwood resigned last year as chief of police of the District of Columbia to work with the district's young children, he said that it had become clear to him that "government capability to control crime and violence depends on prevention...on our capabilities to intervene in the lives of young people before they experience contact with the juvenile justice system." The U.S. business leaders who make up the Committee for Economic Development worried about the lack of qualified youngsters coming into the work force. At first, they focused on high school education, but they followed the causal chain backwards and are now ardent advocates of prenatal care, early education, parent support during pregnancy and infancy, and developmentally sound child care. Similarly, advocates of an enriched and expanded Head Start program recognize that the parent-support, health, nutrition, and child care services it provides must be in place long before eligible children reach the age of three or four.

The first three years of life are a period of great vulnerability and opportunity. The Carnegie Corporation is now documenting how crucial these early years are in human adaptation, how much more complex infants and toddlers are than had been previously thought, and how families can be helped to provide their young children with the foundations of sound physical health, intellectual achievement, and social and emotional well-being. Programs that provide intensive and comprehensive services for the youngest children and their families consistently show effects--whether in improvements in IQ, social competence, or behavior.


SYSTEM MALFUNCTION

These characteristics of effective services differ profoundly from the norm. Most programs and institutions meant to provide services and supports to improve children's lives are fragmented, crisis-driven, and exclusionary.

School counselors are so overworked by daily crises they cannot provide inner-city students with the missing connection to the workworld. A deeply depressed mother may be getting medication for months with no one asking how her baby is faring. Obstetricians take blood pressures but may ignore signs of domestic violence. Child protective workers spend precious hours recording home visits made where no one opened the door and have no time to build relationships with families that would lead them to open the door. Teachers despair of trying to get help for children who come to school hungry, sick, unprepared, and distracted by problems at home, because even the inadequate help that is available is too difficult for them to mobilize. Most frontline professionals feel so overwhelmed by burgeoning caseloads or class sizes and so constrained by rules and conflicting regulations that they have neither time nor energy to develop the connections that help strengthen families.

If we know what works, why isn't it happening? Why is it so difficult to move funds from ineffective services to effective ones?

The prevailing fragmentation and depersonalization of services didn't arise by accident or ill will. Separate funding streams, conflicting regulations, and incompatible disciplinary approaches reflect earnest but isolated attempts to respond to problems that were defined separately and not always understood in a wider context. The result is a bewildering and self-defeating fragmentation of services. For example, in an Albuquerque school for pregnant teenagers, the youngster whose mother is not receiving AFDC (Aid for Families with Dependent Children) can't join a pre-employment class taught by a teacher funded by the Job Training and Partnership Act. In most cities, a woman with a newborn who wants to climb out of poverty faces a dizzying array of obstacles. The drug treatment program won't take her until she establishes Medicaid eligibility, Medicaid won't certify her until she has a permanent address, and public housing won't even put her on the waiting list until she has done something about her drug problem. If she is seeking medical and child care for the baby, drug treatment, family planning, and job training for herself, and housing for the two of them, she will have to go to six different locations, each with different--and often conflicting--rules for establishing and documenting eligibility, each with a time-consuming and cumbersome acceptance process, each with its own Catch-22.

Today's services also reflect the drives of professionals and administrators to establish clear divisions of labor in a world that attaches great value to specialization. In Wyoming, occupational therapists sued the schools to prevent regular classroom teachers from teaching handicapped children to hold pencils.

Bureaucratic and political pressures introduce ever-greater standardization as well as rigid regulation of inputs. Advocacy groups that promote only narrow interventions, rendered exclusively by rigidly defined specialists to a circumscribed clientele, also contribute to the balkanization of services. The process of making essential services coherently available at the local level and getting them funded is now so onerous that only a Mother Theresa who is also a Machiavelli and a CPA can succeed.

Unless we come to grips with the contradictions between effective programs and prevailing systems, successful "model programs" will continue to flourish briefly, only to disappear or become diluted. Especially within large public systems, halfway help will continue to be the norm and to frustrate funders, practitioners, and those they are meant to serve because most systems contain incentives--categorical and crisis funding, large caseloads, and hidebound ways of running large agencies--that undermine the hallmarks of effective programs.

Most successful programs are led by someone who is willing to go against the grain, someone who is willing to ignore or subvert the rules to help the kids. But it does not have to be that way. Prevailing systems can be changed--but only if we are prepared to introduce a new culture into human service systems and into major governmental bureaucracies.

While some see a conflict between those who contend that "we know what works and we can act on it" and those who contend that we cannot act until we "reinvent government," the evidence suggests that these are not conflicting positions. Because we know what works on a small scale and in special circumstances, we must now reinvent government and other major institutions to extend the benefits of what works to much larger numbers.


SEEDS OF REFORM

No one has yet succeeded in putting all the elements of needed change together. However, a number of cities, including San Diego, Oakland, Dayton, Savannah, and Rochester, N.Y., have set up vigorous and innovative cross-system collaborations. Several have undertaken, usually with foundation support, ambitious data collections that have demonstrated how many helping systems are engaged, unbeknownst to each other, with the same family. Many are trying to work toward developing outcome accountability across their health, education, social service, and welfare systems and to use outcome information to shift resources from what isn't working to what is.

Leaders in a handful of states and cities are coming to think in cross-systems terms. School reformers and school administrators know that universal school success can't be brought about by schools alone, and are working with public and private health and human services agencies to develop cross-sector solutions. The superintendent of education in Vermont has agreed with the state's commissioner of human services that Vermont's ambitious education reform will soon be undergirded by a program of nurse home visiting to pregnant women and new mothers. Kentucky's massive court-ordered school reform includes preventive and crisis services from school-based family support and youth service centers.

Perhaps the most successful human service systems reform of the last decade has been the institutionalization of "family preservation" services, for families threatened with the removal of a child as a result of abuse or neglect. For many years the first such program, Homebuilders, operated only at a single site--the Catholic Family Service agency in Tacoma, Washington. Homebuilders is an innovative program in many respects. Its professionals work with no more than three families at a time (one-tenth or even one-twentieth the typical caseload), and they spend up to 20 hours a week with a family initially, giving them time to build trusting, collaborative relationships. Staff members continue to work intensively with the family for six to eight weeks, with meetings taking place in the family's own home and at times of the family's choosing. After crisis-intervention services end, professionals attempt to hook the family up with other sources of support, informal and formal. By the late 1980s, Homebuilders was able to document its success in keeping families together and in saving enough money in averted placements to offset the costs of its intensive program.

The Edna McConnell Clark Foundation became interested in working with the Homebuilders program to spread the family preservation approach beyond Tacoma. The foundation was fully aware that the innovative program would meet some resistance from the mainstream. So rather than simply fund more projects based on the Homebuilders model, the foundation decided to lay the groundwork for systems change. It supported new kinds of training, provided and funded technical assistance to reform their child welfare financing, and helped states to deal with critical administrative matters like changes in employee work rules, union contracts, and public accountability.

Today at least 25 states and several cities are incorporating the principles of family preservation in their reform of child welfare, juvenile justice, mental health, and family support. About 90 to 95 percent of family preservation services are now supported by public funds, and 14 states will have made family preservation services available statewide within the next two years.

Successful programs do not contain the seeds of their own replication, but they contain the lessons on which strategies for their replication can be fashioned. Here are seven such strategies:

1. Outcome-based and results-based accountability. Judging programs by what they accomplish rather than the details of what they do may be the best way to focus attention on agency mission rather than rules and to permit the necessary flexibility and autonomy. Auditors would spend less time reviewing the records of how many services were provided and by whom and spend more time inquiring into the results achieved. Results-based accountability could also go far to restore public confidence in the ability of public programs to use tax money wisely because it could provide evidence on which programs are indeed meeting their intended purpose. The process of agreeing on desired outcomes also encourages cross-system collaboration and can help to promote a community-wide culture of responsibility for children and families.

2. Less bureaucratic, more responsive bureaucracies. The human service paradox is that the very purpose of bureaucracy is to institutionalize the suspension of individual judgment, but that in order to succeed, frontline professionals need flexibility and individual discretion.

Whether it is possible to gentle the heavy hand of bureaucracy is surely central to the question of whether it is possible to scale up from past successes. Current antibureaucratic trends in business, with managers struggling to find alternatives to top-down, centralized decision making, provide some encouragement.

But scholars of bureaucracy, from Max Weber to James Q. Wilson, offer little comfort to those who would develop new models of bureaucracy. Wilson writes that detailed regulations are "of course incompatible with energy, pride in workmanship, and exercise of initiative," and that in large, complex organizations people do indeed worry more about following the right rule than about achieving the ultimate goal. He doubts that much change will happen.

The reasons for imagining that such change could happen are, first, that to a limited extent it is, in fact, happening. Witness the spread of the very unbureaucratic family preservation programs just described and the continued survival of Head Start, which takes a different shape from community to community, and even from neighborhood to neighborhood. In some welfare offices, managers are encouraging frontline workers to move away from an eligibility-compliance culture to one where workers convey higher expectations and actually find ways to help the welfare recipient to make the climb toward self-sufficiency.

We must modify the way bureaucracies function because the stakes are so high and the alternatives so bleak. For if we cannot make public institutions--or even private institutions supported by public funds--more responsive than the current model of bureaucracy would allow, we are in effect writing off those who need effective services and responsive institutions the most. Those who lack the resources, energy, and clout to opt out of public systems are also those who will benefit least from schools, health clinics, hospitals, and social agencies operating in their current straightjackets.

3. Better integrated services. It is almost impossible to provide effective services on a large scale without breaking out of constraints that current financing practices have imposed. By and large, funding sources are so categorical and crisis-oriented that a child or family can get help only if the need can be classified into a construct that the available services happen to fit. Despite the widespread consensus around the value of prevention, this usually means that by the time help is reached, problems have become so severe that the child or family is already in deep trouble.

Some states are getting around some of these difficulties by redeploying resources. Many, for example, are shifting money from foster care to family preservation services. Many schools are funding health services with Medicaid dollars, and waivers may soon allow schools with high proportions of poor children to qualify for per capita Medicaid payments. (Currently, school nurses complain that they spend an hour on paperwork to be reimbursed by Medicaid for a ten-minute procedure.) But more waivers are at best an interim solution.

A promising development with implications for both financing and governance is the formation of public/private entities that serve as intermediaries between small and often fragile local organizations and state and federal agencies. Both the Ounce of Prevention program in Illinois and Friends of the Family in Maryland have been able to nurture and protect neighborhood family-support programs by assuming the burdens of applying for, accounting for, and integrating funding from diverse sources on their behalf, while helping them to train personnel, broaden their community networks, and safeguard quality.

By far the greatest amount of energy and attention of reformers and administrators today is going into interagency collaboration and service integration efforts. Because service integration requires a lot of activity and little new money, and because fragmentation is such a big problem in existing services, many have adopted service integration as a new secular religion.

Unfortunately, communities so dazzled by the process of piecing services together tend to neglect the content of that which is being integrated. Collaboration solves many problems, but it will not improve outcomes if the services that are put together are of mediocre quality and rendered disrespectfully and grudgingly.

4. New definitions of professionalism; new forms of training. Frontline staff today often lack the skills needed to build respectful, trusting relationships, to work collaboratively with families and with systems and disciplines other than their own, and to be comfortable exercising discretion in dealing with a complex interplay of problems. Program managers, in turn, often lack the skills to keep a program evolving in response to changing needs, and to recruit and supervise professionals to work in an unbureaucratic, outcome-oriented organization. Existing training institutions may not all be up to equipping human service professionals with the outlook and skills needed to function in reformed institutions and systems. Many, especially schools of social work and of public administration, will have to change profoundly.

Homebuilders, to illustrate, has trained large numbers of professionals in new techniques of working collaboratively with families on the family's turf and the family's terms. Counseling may happen while mother and therapist work together to clean up the kitchen or to do the grocery shopping. This kind of professionalism requires not only new kinds of training but a redefinition of professionalism that values the acquisition and application of skills that effectively address the messy but urgent problems of disadvantaged populations.

5. Focus on early childhood programs. Since its inception, Head Start has shown that three- and four-year-olds grow up to be better off when they are systematically helped to think, reason, and speak clearly; when they are provided hot meals and health care; and when families and communities become partners in children's learning. Children who participate in good preschool programs do better in school and get into less trouble as adolescents. They are less likely to drop out, become pregnant, or be arrested. That's why there is strong support today for full funding of Head Start.

But now that the nation has become committed to school success for all, now that more and more mothers of young children need to be free to enter the work force, and now that it is clear that the fundamental building blocks of school learning are forged in infancy, long before children reach what we used to think of as Head Start age, full funding of today's Head Start will no longer be enough.

To reflect new realities and new research, Head Start must be expanded--upward, downward, and sideways: downward to support beleaguered families not for one year but for the whole five years of their children's preschool development; sideways to make high-quality services available full day and full year; upward to assure that the children are ready for school and the schools are ready for the children.

The reinvented Head Start of the Clinton era would include all the elements whose cost-effectiveness and long-term benefits have now been established: prenatal care, home visits, immunizations, parent support, and developmentally sound child care. Funding should go directly to existing Head Start programs and through the states to schools, settlement houses, parent-child centers, or other community institutions that recognize that the care and education of young children are quite inseparable.

6. Targeted support to inner-city neighborhoods. The destructive effects of hostile environments on the development of children and on the functioning of parents, which have long been apparent to social services practitioners, are now attracting scholarly attention. Sociologist Frank Furstenberg concluded from his study of the interconnections between disadvantaged neighborhoods and families in Philadelphia: "If we are committed to strengthening the family, we must give more attention to rebuilding local institutions--schools, churches, neighborhood centers, and recreational services--that support families."

Areas of concentrated social dislocation require a critical mass of high-quality services, not just to individually identified children or families in trouble but to entire neighborhoods. Targeted, neighborhood-based efforts could make eligibility dependent on residence and allow services to be designed to reflect the enormous impact of neighborhood life on family functioning and child development.

Previous attempts to target resources on neighborhoods of persistent poverty and social dislocation have never been sufficiently comprehensive and intensive. Even before they were launched, Model Cities, Community Action, and the Area Redevelopment Act of the 1960s were fatally diluted--in each case to cover, with the same resources, 10 to 30 times the number of sites initially proposed. Presidential leadership must now define the common interest in targeting adequate resources on the most devastated inner-city areas and clarify the long-term benefits of such investments from both public and private sources.

Of course, there are risks to concentrating substantial resources on geographic areas of special need. Liberals have traditionally preferred universalism that would incorporate the poor through the political back door. But the effort to avoid a specific focus on the very poor and disadvantaged may by now have become counterproductive, and the politics of the future may be different from the past. We may be seeing the beginning of a greater understanding that all citizens now have a growing stake in assuring that all children grow up with the skills to become productive adults and that no child gets left behind.

7. Leadership that defines the societal stake and encourages bolder thinking. All of the systems-change strategies identified here involve a combination of aggressive action both locally and at higher levels. New thinking must pervade local agencies from health departments to housing authorities to school boards and police departments; state and federal obstacles to change must be removed; encouragement and leadership have to come from every sector of society, including state governments, universities, foundations, and business.

Programs need not only new funds but new kinds of help from the federal government so that they can overcome the barriers of multiple, cumbersome, and conflicting eligibility and reporting requirements; categorical funding; and rigid, centralized micromanagement.This requires a strong continuing federal capacity to monitor state and local progress, learn from experience, and solve problems as they arise.

A White House-led effort, with the authority and the talent to insure cooperation among all relevant agencies and departments, could help to reduce or eliminate barriers to community efforts to integrate effective services, utilize the budget process to promote collaboration, and promote the development of regulatory processes that encourage local innovation, flexibility, and community responsiveness by basing accountability on outcomes and performance.


WHAT WILL IT COST?

Effective interventions do not come cheap. Expanding Head Start as proposed earlier, for example, including steps necessary to strengthen program quality and to gradually extend the program to infants and toddlers and their families, would cost about $24 billion over five years. Expanding and improving state and local child-welfare agency services, including prevention of inappropriate out-of-home placement, will cost about $3.5 billion over five years. A universal vaccine purchase and distribution system will cost about $600 million annually. New costs to the federal government of assuring high-quality health services for all children and pregnant women are impossible to estimate in the absence of concrete details about the Clinton administration's health care reform, but it is likely that insurance coverage of currently uncovered children and the capacity to serve them effectively could be financed from cuts in administrative costs and other savings in current expenditures. An effective federal role in school restructuring and in supporting the educational and related needs of at-risk school-age students depends more on intelligent and strategic use of existing funds than on new dollars. New funds of $1 billion to $2 billion will probably be required to supplement the education and training components of welfare-to-work programs with the supports that would enable even long-term recipients to self-sufficiency successfully and without jeopardizing the healthy development of their children.

How does the country determine whether these investments are worth their cost? The pay-some-now-or-pay-more-later argument ($1 spent on immunization saves $10 in illness prevented, $1 spent on preschool programs or prenatal care saves $3 later, and so on) is valid but has not been persuasive, perhaps because the savings are far removed from expenditures, both temporally and politically. The benefits generally do not show up on the ledger of the same administrator who authorizes the expenditure or during the term of office of its political champion. The savings that accrue because a larger pool of skilled, healthy, motivated young Americans are coming into the work force, the savings in prison costs from a reduction in crime, the savings in fewer youngsters having children before they are prepared to raise them--all these are hard to calculate and to link to specific interventions and seem so ephemeral that they can rarely be turned into up-front appropriations.

Further complicating the cost-benefit calculus is that the move from ineffective to effective services is rarely a matter of taking money from one and giving it to the other. The science of estimating the cost of conversion is so primitive that there simply are no reliable numbers; what is at issue is changing the rules that govern how programs operate, in addition to adding new funds so they will be able to provide staff with additional training and more time to spend with pupils, patients, or clients. Therefore, the dollar costs as well as the benefits of making programs more effective are very hard to estimate, and elegant cost-benefit calculations often obscure the frailty of the assumptions on which they are based.

There is an alternative way of making the judgment. It begins with the recognition that effective interventions to improve the prospects of disadvantaged children are an excellent investment. The failure to make such investments will cost us later. Furthermore, the chances are good that the returns on this investment will be superior to the returns on alternatives whose costs are roughly the same. For example, if we suspend indexing of tax brackets for at least one year (raising revenues of $44.8 billion over five years, according to Congressional Budget Office estimates), or if we raise the top marginal tax rate for individuals by at least 2 percent (raising revenues of $32.2 billion, according to the CBO), we are making choices about how we want to use our national wealth. It happens that either one of these two measures would fund all the costs of the major proposals considered in this article.

In the last decade it has become hard to think boldly. We learned to think small and to content ourselves with fiddling at the margins. But it is rapidly becoming clear that some of our most urgent problems will not be solved unless we dare to adopt a bolder vision--a vision that is built on a shared understanding that we cannot allow the richest country in the world to declare bankruptcy in our civic life and that we can make government work on behalf of all the people.

Today new knowledge and experience provides unprecedented opportunities to transform the widespread yearning to do better into effective and lasting action.

We know we have the elements of past successes to build on, and we know that we can't do it at bargain basement prices, that we can't do it overnight, and that we can't do it without massive change in how major societal institutions function. But we can be certain that if it's done well, it will make a difference in the life of this nation.

Marian Wright Edelman, president of the Children's Defense Fund, says that we are at a point in this country today when doing what is right coincides with what we have to do to save our national skins. The people who are committed to social justice can make common cause with those whose highest priority is a work force that can win the international economic competition.

We now can put in place, on a large scale, the services and supports to assure that all children will grow up to become full participants in tomorrow's thriving communities. But to make that vision a reality, we must be willing to undertake the hard work of reinventing the systems and institutions in which these services and supports can be developed and sustained.

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