By Martelle Esposito and Sasha Reid
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal assistance program that helps pregnant people, breastfeeding mothers, and infants under five access healthy food and education. The program has had remarkable health outcomes since 1972, now serving about 6 million women and children. A JAMA study found that WIC participation reduces risk of infant mortality by 33%, and children who use WIC for their first two years score higher on the Healthy Eating Index. WIC has furthered those outcomes in recent years by modernizing the program. They now offer electronic benefits, a proliferation of apps and tools for WIC participants, and remote service options (fostered by the pandemic).
Administrative burdens create barriers to access
Yet still, WIC modernization overall remains piecemeal, and this continues to create barriers to accessibility for those who need it most: mothers and young children who are struggling financially and going through a profoundly vulnerable, foundational time in their lives.
Take, for example, Jane, a hypothetical WIC participant whose story is a composite of typical experiences. It’s January 2019, and Jane recently gave birth to a baby boy. She works multiple jobs and has an income that falls under 185% of the federal poverty level. She was told by her doctor that she qualifies for WIC, which will help her afford healthy groceries while she’s breastfeeding. But in order to sign up, she needs to visit a WIC clinic in person.
A simple clinic visit might not seem like a huge task. But for Jane, that means a day of lost wages since she doesn’t have paid time off from her jobs. She needs to take multiple buses to get there since she doesn’t have a car. She needs to arrange for childcare, or take her baby with her, disrupting his nap and feeding schedule. When she shows up to the office, if she’s missing any required documents, she’ll have to go through all this again on another day. These burdens add up in time, resources, and mental energy, and they are particularly hard on a new mother who is already stressed. Even after she successfully enrolls, she still needs to re-certify her income and nutrition health assessment in person, annually, to continue to receive benefits.
Jane’s situation represents the experience of many WIC participants. “The distances participants and applicants must travel and the time they must spend away from work are common barriers to WIC,” states the Food Research and Action Center in their 2019 report. A 2021 JAMA study showed that about 160,000 fewer beneficiaries received WIC benefits during the first nine months of the pandemic in states that required participants to reload their benefits in-person or by mail as opposed to an online option. In a landscape report conducted by the National WIC Association and Nava, interviews conducted with WIC staff across the country revealed that “staff widely acknowledged the challenges of the WIC certification process for applicants and participants who are juggling the responsibilities of caring for babies and young children.”
Incremental improvements can make a difference — to a point
Let’s fast forward and say that now it’s January 2022, and Jane and her baby boy, now a toddler, eat meals partially provided by WIC. Due to social distancing restrictions from the Covid-19 pandemic, Jane has been having her WIC appointments over the phone or online at the time and place most convenient to her. She might have a WIC video call from the comfort of her home, where her mother can lend a hand by keeping an eye on her toddler. When she’s up for her annual recertification, she’s able to do that virtually too, as the in-person requirement for annual recertification has been temporarily waived.
Like 80 to 96 percent of WIC participants, Jane is very satisfied with engaging with WIC remotely using options like email, video, and online education. She falls into the quarter of participants who want WIC to remain completely remote after pandemic program operations cease. Carrie Harris, the Yavapai County, Arizona WIC Director, spoke of the positive impacts of remote services on her participants at a recent Nava PBC event:
“We have found in our conversations [with participants during remote services] that often, they are not as stressed. They are in an environment where they are really comfortable versus having to buckle all their kids into the car, unbuckle them when they get to the clinic, and wait in our waiting room. The kid is tired or maybe they want to go home or play with different toys. We have found in situations like this that we actually get a better conversation when they are in their own comfort zones, a lot of times at their own house when their kid has their own toys, or they have someone else, maybe, that can care for them while their mom talks to us.”
Jane’s experience represents the benefits of the substantial progress that WIC has made in recent years modernizing their program. But despite these advances, especially in the wake of the pandemic, WIC staff across the country are still burdened with piecemeal, manual operations processes which vary widely by state agency, especially when it comes to enrollment and certification tools. Up until the pandemic, more comprehensive program modernization had been constrained by outdated policies and limited resources for state and local agencies to build capacity for modern technology projects, despite interest and enthusiasm. WIC programs across the country legally required in-person enrollment before this was temporarily suspended during the pandemic.
Now is the time for technological improvements
But all of this is changing. The WIC community is advocating for permanent policy change. The American Rescue Plan has provided an infusion in funding to the Food and Nutrition Service for WIC program modernization and outreach. The President signed an executive order to improve the customer experience of those interacting with government services like WIC. State and local WIC agencies are energized by the potential of this momentum to use technology as a powerful tool to achieve their vision for a modern, human-centered program.
If there was ever a time to more seriously improve the WIC experience through technology, both in vision and implementation, it’s now.
From our experience implementing human-centered technology and our research on the WIC technology landscape, we know that a more modern technology ecosystem can eliminate current barriers for WIC staff and participants. The new ecosystem would include a collection of both legacy and new modular technology tools connected in a network where data is shared via Application Programming Interfaces (APIs). An API Standard across the nation’s programs would also remove some of the key barriers to innovating and sharing technology tools between agencies.
What we’ve identified in our research is that WIC programs – operated individually by state and local agencies – must accommodate a fractured system of different databases, technological tools, paper records, and manual tools. Each state has a central management information system (MIS) that serves as the case management system for the program. But there are many disparate tools and adjacent, but not integrated, Electronic Health Record (EHR) and referral systems that place the burden of gathering data and interacting with different program areas on both participants and staff.
A participant may engage with WIC using multiple apps and tools, which can be challenging to navigate when, for example, looking for log-in information or making an appointment. “As the participant, a big friction is that we’re getting emails, calls, messages for one-time to log in and stuff. It makes it really confusing and kind of unnecessary,” said Lexi Martinez, a WIC participant from Arizona. “The friction of scheduling [over the phone] is a huge thing because it just doesn’t move smoothly. As a participant, I would like to see that first – to get to be able to make my own appointment on the EZapp.”
For staff, tracking a participant’s data and appointments might require having multiple windows open on their computers to manage all the tools, which can be disorienting and lead to human error. In some agencies, WIC staff are manually entering data – such as participant identifying information – into Excel spreadsheets, then copy and pasting it into different systems, a time-consuming and error-prone process for data management. Even then, the data from MIS is not often accessible in easy-to-use ways for program staff.
For WIC program administrators who want to improve their programs’ systems – such as, by providing an option for online appointment scheduling – are often forced to procure standalone technology tools to try to more quickly meet the needs of their participants. This often leads to staff manually navigating and sharing data between multiple tools. Alternatively, administrators could extend the functionality of the MIS, say building that online appointment scheduling application on the MIS platform so that it can easily access its data. But this requires a lot of time requesting, planning, and waiting for MIS systems updates. The latter is further complicated by the state consortium model in WIC, which requires member states to agree on changes to shared MIS used in the different states. This means that if a state wants to try something new, it must get approval from the other states first.
How MISes can create barriers for WIC agencies
Many of these challenges arise from the MIS. Each MIS is like its own walled vegetable garden – a closed and controlled space unique to each state. These walled gardens have advantages, such as security. But they also make it hard to share vegetables — e.g. features like online scheduling or applications like EZapp — with other states. New vegetables must be grown within the walls of each garden, which often means making the garden even bigger, more complex, and interdependent to its own system.
These MIS systems make it challenging to bring in new features, such as a scheduling app for participants, because they need to be built specifically on the MIS platform, or within the walls of the garden. This further locks an agency’s technology ecosystem into a single MIS with a single vendor.
Alternatively, agencies could build and buy features that function outside of their MIS systems, like growing their own tomatoes outside of the walled garden. But these “outside” features require staff to manage and maintain them. For WIC agencies, that means procuring technology features that require maintenance through staff support. WIC staff might need to manually export and input data regularly from outside technology tools into or out of their MISes, which in turn causes a delay for participants.
The current MIS systems, while capable of incremental innovations within WIC agencies, are set up within a broader technology ecosystem that makes more prolific change challenging. There’s a better way for staff, administrators, vendors, and ultimately, participants.
An API standard would foster tool sharing between agencies
When it comes to navigating multiple siloed systems, Application Programming Interfaces, or APIs, are an excellent solution. APIs connect disparate, fractured systems, allowing agencies to adopt new tools or practices without having to build within an existing system.
Let’s say you’re using a webpage or mobile app to shop for something on the internet. Your actions in your browser call an API, and that API carries out your request on servers in the cloud before sending your results back to your device.
APIs can provide a “farmer’s market” of produce outside of these vegetable gardens. The walls around the garden still exist, but now there are organized tables outside of the garden walls with clear signs indicating where each vegetable is located. Tomatoes – say, an online scheduling application – can be shared easily between different walled gardens.
APIs empower agencies to adopt the tools they need without adding burden to their applicants, staff, or both by adding more less standardized and interoperable access to data. If the API standard is implemented well, states can build and procure the tools they need for their program with fewer constraints from their MIS.
Meanwhile, developing a WIC-specific API standard across MIS would create a shared, well-defined format for accessing and interacting with data. That means that a tool that provides online appointment scheduling could be developed as a modular software component that works with any MIS for any agency across the country that wants to deploy it.
Empowering agencies to meet their participants’ specific needs
An API standard is especially powerful because it’s flexible enough to meet a variety of needs. The potential issues outlined so far might only apply to some WIC programs, while others might have different issues. WIC program leaders know their communities’ needs best and an API standard empowers agencies to build tools that meet their participants’ specific needs. These tools can then be plugged-and-played into existing systems, as well as shared across different programs.
Moreover, an API standard has the potential to eliminate vendor lock-in and open WIC up to modern software practices and promote greater competition and incentive for modernization. A shared API standard applied uniformly across WIC would mean that each of the 89 individual WIC state agencies would not need to design and build their own API from scratch. This would ultimately reduce risk and effort on already time- and resource-strapped agencies, and foster interoperability across WIC state agencies.
An API Standard would leverage the positive impacts of a technology ecosystem – the flexibility and power to add new tools using different vendors – while eliminating constraints because these tools could interact with existing MIS.
How stakeholders benefit from an API standard
- Have the tools they need to access, understand, and engage with the program, tailored to their unique needs and preferences
WIC frontline staff:
- Have easy access to participant data from various technology tools in one place without manual data tracking between different tools, so they can spend less time on these administrative tasks and more time engaging with participants in core program services
Local WIC Agencies:
- Can create/obtain tools that meet the unique needs of the populations they serve and offer data access with existing MIS without making changes to the MIS
State WIC Agencies:
- Have the flexibility to respond and adapt to evolving population and program needs through updating, replacing, or adding specific tools or modules, which is a quicker and easier process than making changes to large technology systems
- Are able to leverage the collective strengths of state consortiums of pooling resources and sharing technology tools between states while independently pursuing new tools to meet the needs of their particular state’s participants and staff
- Are able to work with a range of vendors for different technology tools and are not constrained by the technical limits of the MIS or other data sources
- Are able to reuse/license modules or tools that other state agencies build because the MIS are now all interoperable
- Can offer products across multiple WIC agencies, independently of the MIS those agencies use
Food and Nutrition Service:
- Can build technology tools agnostic of a particular MIS that any state can choose to uptake
- Can leverage resources to scale technology tools across states WIC program, collectively
- The best technology tools get developed, scaled, and used to support a participant-centered program
Better customer experiences for WIC staff and participants
Let’s revisit Jane, our time-strapped mother forced to go into an office to enroll in WIC. Let’s say that Jane’s local WIC agency has adopted a number of new digital tools using an API standard, such as online enrollment and annual recertification as well as virtual nutritional classes. WIC administrators, who seek out participant feedback and understand best what their communities need, were able to bring each of these features into their program technology system using modular, API-based tools that plug into their existing MIS. They were able to work with different vendors for each tool, providing flexible, cost-effective choices. Data can be shared between each of these tools, meaning staff do not need to manually enter data between systems, for example between an app used for scheduling and the MIS that stores participant data.
As a result of this continued innovation – made easier by policy changes pushed forward by advocates as well as the implementation of a national API standard – Jane’s life has gotten a little easier. She no longer has to take a day off of work or multiple bus trips, or find childcare in order to enroll – instead, she can do so online at her chosen time and place, using a document uploader to enter in the required information to apply. If she’s missing some required information, she can save her application, hunt it down, and submit it after it’s complete.
Once she’s enrolled, it’s time for Jane to make an appointment for nutrition counseling. She can make the appointment online and complete it via video chat, providing her more options beyond an in-person appointment. And she no longer has to make multiple trips to both her primary care provider and WIC for weight and height checks since her information is sent from her primary care provider directly to WIC.
For the WIC staff working with Jane, that’s one less disappointed family that has to come back to the WIC office to continue to receive benefits. It’s one less phone call to handle scheduling. They don’t have to do redundant height and weight checks. They can focus instead on providing the best care they can to participants. Meanwhile, WIC program administrators are able to track Jane and her baby’s progress along with other participants in their community, keeping an eye on outcomes and trends that can help them make decisions and bring additional tools pertinent to their communities’ needs. For example, states that moved WIC benefits from paper vouchers to electronic benefits transfer (EBT) cards between 2014 to 2019 saw a 7.78% increase in program participation compared to states that didn’t. These are the kinds of outcomes that administrators can monitor.
WIC has time and time again proved itself to be an enormously important and successful federal program. WIC models how public benefits can impact health outcomes for an essential group: young moms. Dedicated WIC agencies have already embraced innovation, bringing what modern tools they can into labyrinth-like legacy systems and MISes. It’s time to help them continue this modernization effort by adopting solutions like an API standard across the country.
Special thanks for input and feedback to Jessi Bull, Daniella DeVera, Sara Distin, Domenic Fichera, Diana Griffin, Rocket Lee, Lauren Peterson, Karen Turner, and Lowell Wood.