5. Conclusions and Recommendations
ConclusionsThis study was undertaken to identify ways in which to improve the provision of child development services in the military. To better understand the Child Development Services (CDS) system, we visited military installations around the country and overseas, and interviewed a wide range of people involved with military child care. Our data revealed an ambitious system of employer-sponsored child care that is far more progressive than that provided by the vast majority of private employers. At the same time, we identified a number of areas in which improvements could be made that would benefit parents, children, and the military.
The principles underlying military service--that one's service responsibilities can, if necessary, take precedence over all other responsibilities, including parenting, and that service responsibilities may involve long hours and odd hours--create significant challenges to the provision of child care. Increasing numbers of working spouses, single parents, and dual military parents further complicate the task. As currently structured, the challenges in the delivery of military child care include tradeoffs between the construction of military facilities and child development centers, between child care for the few and recreational services for the many, between limiting center child care hours for the sake of breaking even and knowing that those hours sometimes do not allow parents to fulfill their military responsibilities.
The Child Development Services systems that have evolved reflect the contradictions inherent in these tradeoffs. Three areas stand out; we present them here, then make recommendations about each below.
- First, the goals of CDS are not clearly defined, and consequently remain multiple and often inconsistent. Moreover, the goals are often not expressed in practice.
- Second, once the goals have been more clearly specified, there needs to be a systematic way of determining the amount of child care that should or will be made available. Although there is considerable consensus that child care is not a benefit on the order of medical care, the amount that should be provided and the way that the level of services will be arrived at have not been determined. Nor is it clear who should have first call on these services. A major factor that inhibits such efforts is the limited amount of data on the demand for child care and about the real costs of providing it. Currently, demand is generally assessed through waiting lists. But with widely varying policies and levels of monitoring, they are at best crude indicators of demand. With a few notable exceptions, efforts to improve demand assessment have yet to be made.
- Third, the degree to which the military will or should intervene to create a better integrated system of child development services that deals with current service gaps has not been addressed. The heavy reliance on CDCs promotes "fair weather" readiness, providing care to many children and freedom from worry and child care responsibilities to many parents, as long as children are not ill and their parents are not deployed or working especially long hours. Inconsistent regulation and beliefs surrounding the delivery of child care outside of CDCs complicate the potential for system integration, despite its promise for addressing readiness goals more adequately.
RecommendationsBased on our interviews and secondary analyses, we make a number of recommendations about ways to improve the management and delivery of child development services on military installations. Our recommendations are based on the perspective of military child care as employer-sponsored child care, which implies that child care programs must benefit the employer as well as enhance the welfare of the children who receive services.
The goals of military child care should be specified and efforts made to address these goals through CDS operations and priorities.The goals of military child care are multiple and at times inconsistent. Our respondents described many goals, including readiness, family economic well-being, retention in the service, increased parental work efficiency, parental peace of mind, respite for parents, enrichment for children, and an enhanced image for the military that might translate into improved recruitment. The multiplicity of goals reflects different child care constituencies and the failure of policymakers to clarify which groups and which needs it will satisfy. It is important to clarify the goals of the CDS system, and to act to ensure that the goals are expressed in practice. For example, if readiness is a key priority, then priority for child care should reflect the readiness goal. Retired military, who do not contribute to current readiness, should be given a lower CDS priority than, for example, civilians in key jobs on the installation. Efforts to provide regular care in settings consistent with readiness, for example, directing single parents to FDC, should be made. A systemic approach to the provision of care, in which a key system goal is filling gaps in regular care, should be undertaken.
Efforts to reassess and monitor priorities should, to the extent possible, include specific goals for meeting child care needs. Such targets (e.g., serving all single and dual military parents) will provide a yardstick against which the CDS system can be evaluated. Without specific goals, it is impossible to evaluate how well the system is working; specific goals also make planning easier. The Navy has taken an important step in this regard by developing targets for the intensity of CDS. A recent document specifies that the Navy will endeavor to provide CDS to 100 percent of single-parent and dual military families and to 30 percent of other families.
The measurement of demand should be standardized and the cost per slot of care in CDCs and FDC determined.The CDS system needs to improve both the way it measures demand and the way that costs are assessed and resources allocated. Fundamental to improved demand assessment is the need to understand more clearly the demand for child care and the meaning of ubiquitous waiting lists. As discussed above, waiting lists may include parents who cannot work because unsubsidized care is not available, families whose current care is suboptimal in terms of quality, and parents who prefer subsidized care because it is less expensive and perhaps more convenient. Respondents everywhere believed that nearly all parents found alternative child care when the CDC--parents' first choice in most instances--was unavailable. They also believed that many of these parents could be found on CDC waiting lists, contributing to excess demand statistics. On a few installations, policy on this point had been established; often, it specified that the installation had an obligation to offer military child care to all families, but not their first choice. In most places, however, the issue remained unaddressed.
Standardize Waiting Lists. The first step toward a better understanding of waiting lists is to make all waiting lists uniform within each service, and preferably across services as well. Furthermore, procedures for keeping waiting lists should ensure to the extent possible that duplication is avoided. For example, central waiting lists should be kept within each local market. In areas with different installations close together or installations that house members from different services or multiple CDCs, there should be a centralized waiting list for everyone.
The waiting list application should elicit information about current child care arrangements and the reasons for seeking care in the CDC (or FDC). Demographic information about the parent(s) should also be obtained. Information on the waiting list should be updated at regular intervals so that it will be reliable for analysis.
Analyze Excess Demand. Streamlining waiting list procedures will provide additional information, but will not, as discussed above, suffice to estimate the excess demand that causes parents to leave the labor force or that results in child care arrangements of suboptimal quality. To assess these issues, it will be necessary to examine the relationship between child care costs, labor supply, and child care arrangements. A first step will be to examine the evidence from the civilian sector and determine the extent to which models of child care costs and labor supply might be applied to military data. The second step will be to build a model of the demand for military child care that could be used to predict the future demand for such care.
The Air Force and DoD have begun developing models to predict child care usage. These models need to be further developed and validated. A demand study, discussed below, should include such validation.
Improve Cost Estimates. Currently, CDCs receive substantial subsidization, and as a result charge fees that are lower than many of the (unsubsidized) FDC providers and the civilian day care centers in surrounding communities. This contributes to the strong parental preference for CDCs. Our data reveal that there is little understanding of the cost per slot to the government of providing care in different settings. Many respondents appear to overestimate the costs to the government of providing FDC while substantially undervaluing the costs associated with construction and maintenance of CDCs.
As long as these costs remain largely unknown, the DoD will have no empirical basis for reassessing resource allocation decisions within the CDS system. To allocate resources more efficiently, we recommend that a cost-effectiveness analysis of CDCs and FDC be undertaken. To perform a cost-effectiveness analysis, however, it will be necessary to first assess the steps needed to improve FDC quality, so that the FDC can become a viable alternative to CDCs in the minds of parents. The cost of improving the quality of FDC would be included in the cost-effectiveness analysis.
A more systemic approach to the provision of child care should be considered.CDS does not function as a system in most places. The bulk of administrative time and attention focuses on the CDC, a focus that has increased substantially since the passage of the MCCA. FDC receives minimal attention, and in most places, other services, such as information and referral, are limited, if they are available at all. Youth Activities is often administratively removed from CDS, despite the growing tendency for it to provide child care to young children, and it receives minimal oversight. Moreover, there are no system-level goals, such as helping parents find and use the most appropriate care setting, or helping parents fill inevitable gaps in care created by child illness or work demands. It seems worthwhile to explore the efficacy of a systems approach to child care in which CDS provides both a range of regular care options and backup options when normal care arrangements fail. Such an approach holds promise for promoting parent, child, and military goals.
Help Parents Find Alternative Care. Under current practice, attention focuses on each of the separate components of the system, leaving even high-ranking parents scrambling for care when the regular source of care cannot be used. Some monitoring of the need for and use of night and weekend care would help CDS staff to identify families that might be better served in FDC. A systems approach would encourage CDS staff to talk with such families and encourage or direct them to the care setting that is most likely to meet their needs.
The need to provide flexible care options should begin with an assessment of readiness losses resulting from inflexible care. Our analyses of the Survey of Army Families data revealed, for example, that parents lose more time from work for child care reasons when their children use the CDC than when they use FDC, despite widespread beliefs to the contrary.
Providing care when the regular provider cannot be used is especially important for those who rely on CDCs. There, the strict implementation of sick child policies and limited hours appear to create problems for parents whose children are ill or who must work long hours or weekends. To facilitate the provision of such care, someone on each installation might be designated to help parents set up a backup system that could be quickly activated if such care is required or to arrange for care on short notice. A program through which on-call FDC providers make evening and weekend care easily and formally available might be another way to help parents and the military address readiness goals. Parents who learn of extra duty requirements could contact the CDS staff member responsible for such care to obtain the name of the FDC provider who will be on call at the time extra care is required. The parent could then fairly easily arrange for care and for the transition to it. Such a system would require children to change providers, particularly if their normal source of care is the CDC, but such children generally must make the transition at these times in any case.
A program similar to the Health Care Finder program developed by the Air Force might also be considered. This program obtains a medical appointment in a military facility or provides care-seekers the name of a civilian provider who has agreed to limit fees. This program is expanding at a rapid rate, despite liability concerns similar to those that exist for child care. Such a program for child care might help parents who have just arrived at a new installation to find regular care, and could also help parents who need extra care to find it. Although some cost would be involved in setting up such a program, reduced losses to readiness and greater use of non-CDC providers might compensate.
Provide More Flexible Care. Our interview data point to strict implementation of sick child exclusion policies in the CDCs as a major contributor to lost work time. We recommend that consideration be given to the revision of sick child exclusion policies along the lines of new guidelines recently issued by the American Academy of Pediatrics and the American Public Health Association (AAP/APHA, 1992). Based on evidence that the exclusion of children with mild illnesses may serve little preventive function, the new guidelines encourage children who are only mildly ill and feeling reasonably well to be allowed to continue in group care.
Policies that do not permit CDC staff to administer medications to recovering children also appear to interfere with readiness. Whether or not they administer medications, caregivers should be aware of possible drug reactions to the small number of medications commonly prescribed. It is a small step then to permit designated caregivers to administer these medications, but one which would be of immense help to the military and to parents.
Examination of other approaches to providing employer-sponsored child care in situations that are similar to the military (e.g., irregular and long hours) would also be worthwhile. A number of civilian employers have established programs to serve the children of such employees. Analysis of these programs would shed light on new options that might provide more flexible care for military families.
Reexamine Organizational Location. The organizational placement of CDS deserves attention as well. Although there are arguments on both sides concerning the appropriateness of CDS being in MWR, it seems clear that placement under recreational services accords CDS no benefits but levies considerable costs. We recommend that CDS be removed from recreational services, and that its placement in MWR be reconsidered.
The DoD should consider increased integration of FDC into CDS with respect to provider training, provider income, and distribution of services.FDC is clearly the poor stepchild of the current Child Development Services system, the nonpreferred alternative for parents and command alike. Yet FDC has the potential to provide care that generally is not provided in CDCs--weekend and late-night care, and care for infants and toddlers that is superior in terms of both physical health and cognitive and emotional development. Moving infant care to FDC, as has occurred on a few installations, would open CDCs to more children, as child-to-staff ratios for older children are higher. This would serve the important system goal of better meeting demand for child care.
For FDC to reach its potential and better address CDS system goals, a number of actions should be considered:
- Strengthening FDC Provider Training and Oversight. FDC providers currently are subject to varying training requirements across installations. If they received the same training everywhere and that training was the equivalent of the training required of CDC caregivers, a major disincentive would be removed to becoming and remaining a FDC provider: the need to undergo retraining at each new location. Moreover, providing FDC providers the same training as CDC caregivers receive conceivably could lead to improvements in both perceived and real quality of FDC.
- Marketing FDC. An assessment of parent and command concerns about FDC, to be followed by efforts to address these concerns, might be a first step in attempting to make FDC more attractive to both parents and command, thus reducing unmet demand for CDC care. Data that show reduced illness and improved cognitive and emotional development in infants in FDC (e.g., Johansen et al., 1988; Anderson et al., 1988) could be presented to parents with an infant or toddler who apply for a slot in a CDC. This information might help them make more informed decisions about the type of care they wished to buy. Data which show fewer days lost to work for parents of children in FDCs could also be provided to parents and the command. A detailed study of the cost-effectiveness of FDC and CDCs would help to clarify advantages and disadvantages of CDC and FDC care. Such a study would also have to consider what quality improvements would have to be made to bring the quality of FDC care up to the level provided by the CDC, and the cost of such improvements. Such a study would help in future resource allocation decisions, and, if FDCs prove to be more cost-effective, would provide additional arguments for integrating FDC into the CDS system.
Subsidizing FDC. Consideration should be given to using the authority to subsidize FDC granted in the MCCA to achieve military, parental, and child goals. Currently, unsubsidized FDC appears to result either in high fees that drive parents to CDCs and inflate waiting lists with families already receiving FDC, or in FDC providers subsidizing parents by charging low fees, which creates a disincentive to provide that care.
Subsidies might allow some FDC providers who currently charge close to market rates to charge less for care, which could help to reduce demand for CDC care and encourage use of FDC. At the same time, subsidies might enable providers to earn enough that they would be motivated to enter and remain involved with the program, reducing the FDC provider supply problems that we encountered on some installations.Selective subsidies that further military and child goals should be particularly explored. Since infant and toddler care is the most expensive care to provide in CDCs, and since infants and toddlers benefit more from FDC than CDC care, subsidization of FDC providers who provide infant care would be an appropriate policy to consider. Selective subsidization might open more infant slots in FDC, which would allow CDCs to focus on children three and older, who have been found to benefit most from group care.
Reducing Provider Disincentives. The disincentives to provide care through FDC are many and varied, including low wages, high start-up costs, retraining at each move, long work hours, and limited or no backup support. To improve FDC quality and supply, consideration should be given to ways that the DoD might reduce or remove each of these disincentives.CDS-issued equipment, elimination of retraining requirements at each move, and formal procedures for ensuring that FDC providers can call on reliable backup care might help to increase the appeal of FDC substantially, and would thereby increase both quality and supply. Improved compensation for FDC caregivers might also increase its appeal to potential providers. Although the DoD has chosen to remain uninvolved in FDC compensation, it might be worthwhile to revisit this policy.
- Targeting of Child Development Services. Greater integration of the CDS system might well include efforts to help parents not only find care, but find care that best meets their needs, their child's needs, and the military's needs. FDC appears on the face of it better equipped than CDCs to handle irregular or long hours, or care for slightly ill children. Numerous respondents freely identified CDC families who they felt should be using FDC, either because it was a single-parent family, both military parents had a Military Occupational Specialty (MOS) that required a good deal of time away, or for other reasons. But few felt comfortable directing or even suggesting that the family receive care from an FDC provider. Given the emphasis on CDC and, in some cases, the priority accorded single parents for CDC care, a policy that promotes the matching of families with the most appropriate care setting should be considered. If such matching proves to be acceptable and effective, it would help the CDS system to better meet readiness goals and provide children more consistent care.
A systematic assessment of Youth Activities and its increasing involvement in the provision of care to young children should be initiated immediately.Youth Activities provides child care to growing numbers of young children, and does so with little regulation or oversight. In the YA programs that we visited there were no required child-to-staff ratios. Safety regulations that have required many CDCs to undertake costly remodeling projects do not apply. Whereas CDC caregivers were tackling new training curricula developed in response to the pay banding component of the MCCA, training for YA staff was minimal at best.
This limited regulation becomes more problematic as younger children are served by YA, and YA's mission consequently shifts from exclusive provision of recreational services to the provision of child care.
An assessment of YA should include an examination of the involvement of Youth Activities in providing child care as opposed to youth activities, and the implications of this new mission for staff qualifications, age integration, and the need for regulation. If it is determined that YA should provide before and after school care, it is imperative that new health and safety regulations be implemented and funds committed. If not, then measures to discourage parental use of YA as child care for young children should be identified and implemented. Continued lack of regulation of child care to young children simply because YA provides it cannot be countenanced. Integration of YA into a revitalized CDS system should also be discussed.
Administrators should be educated about child care quality.Overestimates of CDC quality were common in our visits, and resulted at least in part from lack of experience with a range of child care settings, particularly exemplary ones. Education of command and child development staff about what constitutes quality would address this problem and perhaps increase motivation to improve the quality of care. Such education could occur by visits to "model" settings (CDCs and FDCs) and through briefings, perhaps at commander conferences. The Demonstration Program for Accredited Centers mandated as part of the MCCA holds promise as a means of identifying program models that appear to be effective in fostering child development.
However, as discussed above, we know that some parents leave the labor force if nonsubsidized care is not available. Very long waiting lists may lead parents to believe that they will never receive subsidized care.
D. Peabody, American Public Health Association, personal communication, June 6, 1991.
A model for such an integrated approach may be found in the military health care system's "coordinated care" structure.