3III.D.1. Expenditures 

Overview of Expenditures: 

The Title V MCH block grant, together with local funds (state match) and other additional federal funds, is used to address American Samoa’s MCH priority needs, improve performance related to targeted MCH outcomes, and expand systems of care for CSHCN populations and MCH. The mission of the AS Maternal and Child Health Program (AS MCH) is to promote and improve the health and wellness of women, children, including children and youth with special health care needs (CYSHCN), and their families by supporting and promoting quality prevention programs and effective partnerships. The MCH Program works towards achieving this overarching work through the ASDOH Tafuna Health Centers and its satellite clinics, its internal and external partnerships including the LBJ Hospital.

In the budget allocation for FY2022, the Title V federal allocation included one third of funds to support Children with Special Health Care Needs (CSHCN) and an additional one-third to support the MCH priorities for preventive and primary care initiatives for children ages 1  to 21 years of age. FY2021 budget was initially aligned according to state action plan initiatives. These initiatives included direct services for CSHCN; enabling services for all population domains; and supporting public health services and systems to improve overall health for all women and children.

In the pie chart below, it provides a snapshot of the budget  allocation for the FY 22 by federal funds, state match and other federal funds which are under the Title V program Director’s oversight.  A total of $494,000 Title V federal funds (50.7%), a local match of $390,000 (40.0%) and other federal funds of $91,012 (9.3%)that included SSDI and Zika MCH Services funds.

The AS MCH program will expend all funds awarded for FY 22 of $501,126 by the end of the project and budget period. During the Project Year 2022, from 10/01/2021 through 07/28/2023, the MCH Program expended total funds of $487,070. The current encumbrance figure is $11,088 and the total unobligated amount is $2,969. The total unobligated amount of $2,969 is allocated for Wages, Salary and Fringe Benefits. The encumbrance amount of $11,088 are under contractual which includes MCH Title V Office Lease for the months of August to September, as well as CYSHCN hospital facility fees (outpatient, inpatient, diagnostic testing and medications).

Legislative Requirements Met: 

The AS MCH is continuously striving to ensure that the program is complying with the legislative financial requirements for the Title V Block Grant. The AS MCH Title V Program Director (PD) generates monthly financial reports from general ledgers on One Solution, which is the electronic financial database for all of the American Samoa Government (ASG) agencies. These reports include total funds available, funds expended, and funds encumbered. For each purchase expended, as well as salaries and wages posted on the labor distribution reports, the spreadsheet documenting the 30-30-10 percentage is updated. This ensures the program continues to be in compliance with this legislative financial requirement. The Title V legislation requires a minimum of 30% of the block grant funds to be utilized for preventive and primary care for children and a minimum of 30% of the block grant funds for services for CSHCN. In addition, no more than 10% of the grant may be used for administration costs.

In the chart below, it depicts the overall percentages of MCH Title V federal funds expended per types of individuals served. In the original budget proposed, 30.3% ($150,000) was allocated to preventive and primary care for children, 30% ($148,200) for CYSHCN and 0% for administrative costs. According to the 2023 grantee review summary, it was not clear how administrative services were paid for FY21. Hence, this report is a more accurate representation of what actually was spent in 2022. More time and effort was utilized in administering vaccinations by MCH funded clinical staff, including the Title V director. Half of her salary was utilized for administrative costs which is reflected as 8.4% of funds expended. The other half of her salary had funded preventive and enabling services for children during the COVID-19 community outbreak.

This is also the case for the Licensed Practical Nurse and nurse practitioners. This is also reflected in the above chart, with 40.0% of federal funds were expended for school COVID vaccinations (as well as school catch up vaccinations in the summer) and school screening for RHD in the month of September. Other activities were also focused on children ages 1 through 21 years, which included monitoring and answering the 220 suicide warmline afterhours, epi surveillance and generating daily and weekly health messages to promote vaccinations, screening and treatment for COVID-19, taylored to children and parents. Despite the presence of supplemental COVID-19 funds available to assist the Community Health Centers, MIECHV and the Immunization Program etc. MCH staff were deployed to assist with the COVID-19 operations because there were not enough experienced staff available for hiring. More federal funds were expended to serve CYSHCN with 32.6% of funds expended for this population. This was due to better coordination leading to more clients and families enrolled, and more support from leadership in addressing the needs of this population. American Samoa has met the 30-30-10 percent legislature.

Other Federal Funds: 

Other Federal Funds under the direct authority of the MCH Title V Director which are also listed in Form 2 includes the State Systems Development Initiative (SSDI). The total expenditure was $35,744. A no cost extension will be requested to utilize the unobligated amount of $14,256 to be expended by the end of the FY 2023. Also, a total amount of $41,009 of the Zika MCH Services funds were fully expended.

Total State Match: 

The Total State Matching funds in the amount of $428,928 was expended for FY 2022. The majority of the total Other Funds/Total State Match were expended towards locally funded MCH personnel salaries for staff, all logistical expenditures for RHD school screenings, and Central Well Baby Clinic utilities, medical supplies and maintenance. Majority of the local match funds were for enabling and public health services for children and CYSHCN. The actual total amount of in-kind support provided by ASDOH and ASG to the maternal and child health population continues to exceed the amount reported on the Title V MCH program expenditures. This also includes administrative costs procured by ASG offices including DHR, Budget Office, Office of Procurement and Treasury as they support hiring, procuring and processing of purchases, travel and payroll. However, the Title V MCH program can only report budgeted salary percentages and expenditures ASDOH can view in One Solution.

Payer of Last Resort

American Samoa DOH strongly supports Title V regulations to use Title V funds as the payer of last resort. The comprehensive Title V-Title XIX IAA signed back in 2018 is still in effect. Title V and Medicaid will need to meet and add on the agreement to comprehensively define what is Medicaid going to reimburse in terms of newborn bloodspot screening. The remaining Title V funds are used for systems-level work in infrastructure or related to the ten essential services which are non-claims related reimbursement.

III.D.2. Budget 

Budget Overview: 

The mission of the AS MCH is to promote and improve the health and wellness of women and children including children with special health care needs, and their families by supporting the delivery of quality prevention programs and effective partnerships.

The MCH Program’s State Action Work Plan has been developed based on the Needs Assessment and current emerging issues. Therefore, the MCH Program’s State Action Work Plan determines where the MCH federal grant dollars are budgeted. The MCH grant, all Other Federal Funds, and the Total State Match continues to align its overarching goals and objectives to effectively leverage resources to serve the MCH population. The Title V funds consist of personnel salaries and fringe benefits that support the following staffing: Title V Program Director, 4 CSHCN Care Coordinators (2 vacant for hiring), RHD Client Navigator, Nurse Practitioner, CYSHCN Director/RHD Program Coordinator, Pulmonary-Cardiac Echo Tech, Nurse Assistant/Health Educator, and Licensed Practical Nurse. Half of the Title V Program Director’s salary and one-third of the finance officer’s salary accounts for the administrative cost, a 9.8% of total Title V funds.

In addition to personnel salaries and fringe benefits, Title V funds are budgeted towards Public Education and Awareness, Supplies and All Other Costs to support the MCH Programs activities and initiatives stated on the State Action Work Plan. For instance, public education and awareness costs include print, radio, local newspapers, television and social media posts on the importance of preventive screenings, annual preventive visits and prenatal care. Community awareness includes publicizing available services and programs such as, home visiting, immunization, and other available health services that cater to the MCH population. The MCH Program will continue to educate the community on the importance of preventive screenings among infants, children, adolescents and women populations. Title V funds will be utilized towards family support materials for prenatal care programs, children and adolescent focused activities including RHD prevention, Women’s Health Month, breastfeeding support and other community outreach events that serve the MCH population. Funds are also utilized towards other costs such as travel, repairs and maintenance, communication services costs, office space rental, and so forth.

The table below provides an overview of the AS MCH FY 2024 Budget as reported on Form 2. Majority of direct services will include school screening for  RHD, routine check-up of diagnosed children to monitor their status as well as compliance with secondary antibiotics, physician visits for CYSHCN as well as hospital charges for inpatient and outpatient services, medications, laboratory services, DMEs and dental. The rest of the Title V federal funds will be focused on providing enabling and public health services to include care coordination, health promotions, training and competencies, policies and MCH epi surveillance.

Legislative Requirement:

The AS MCH Program is continuously striving to comply with the legislative financial requirements for the Title V Block Grant. One of the major duties and responsibilities of the Program Director is to continuously ensure Title V federal funds are budgeted and expended per the minimum required 30-30-10 percentage. A monthly expenditure report will be prepared consisting of current funds available, funds encumbered, funds expended and the legislative required 30-30-10 percentage report. The Fiscal Year 2024 Title V Block Grant budget proposal of $510,000 consists of the following types of individuals served: 30.6% at $156,000 for preventive and primary care services for children ages 1 through 21, 31.2% at $159,000 for CYSHCN (direct, enabling and public health services) and 9.8% at $50,000 for administrative services. Pregnant women and infants less than 1 year of age are budgeted at $78,000 which are mainly public health services.

The table below provides a snapshot of the required federal allocation for the FY 2024 Budget. Based on the expenditures for 2022, it is estimated that the percentage allocation in FY 24 for preventive and primary care for children is 39%, the CYSHCN at 31% and administrative cost at 9.8%.

Other Federal Funds:

Other Federal Funds budgeted that are under the direct authority of the MCH Program Director will now include SSDI and Newborn Bloodspot Screening Propel Grant. The Other Federal Funds under the control of the MCH PD is responsible for the administration of the Title V program budgeted for the estimated amount of $445,000.

Total State Match:

The MCH match is budgeted at $420,200 which comprises the ASDOH in-kind funds which will comply with the required FY1989 Maintenance of Effort amount and more. Therefore, the Federal-State Title V Block Grant Partnership subtotal is $1,375,000. The Total State Match funds are budgeted towards personnel salaries and fringe benefits for locally funded MCH staff as well as those enabling public health services and systems for children and CYSHCN.