More than four years after the new Martha’s Vineyard Hospital was required, as a condition of its expansion, to spend $2 million on community health programs, not one dollar has yet been spent on initiatives not directly connected to the hospital.

Under the terms of approval by the state Department of Public Health, the hospital was supposed to begin distributing the money in January 2006. The five-year timetable for the expenditure meant it all should have been distributed by January 2011.

In reality less than half the money — $925,000 — has been spent by the hospital, essentially on its own operations, recruiting and retaining primary care physicians.

It is expected it will be at least another three months before any of the remaining money begins to flow.

A committee of Vineyarders, including town health agents, people connected with the hospital and others involved in the provision of health services, is now finishing the paperwork for requests for proposals from groups which want a share of the $1 million remaining and available. They hope to complete the RFP at their next meeting, this coming Wednesday.

The proposals then will be assessed, and initial funding will begin in October. At the hospital’s insistence, the money will be spread evenly across each of the five years, $200,000 per year.

The bulk of the money, $900,000, will be distributed in grants of between $10,000 and $60,000 per year. Grant duration may range from two to five years. Grants of more than three years’ duration maybe renewed after three years, subject to assessment of the programs’ effectiveness.

Another $100,000 will be allocated as one-year “mini-grants,” of between $1,000 and $5,000 each.

This is no doubt an encouraging development from the perspective of the cash-strapped Island towns and community health advocates.

But the central question remains: why did it take so long?

Several people involved in the process and not connected with the hospital blame it for deliberately dragging its feet. The hospital points to a long and involved consultation process. And the state health department does not want to talk about it.

There are other questions, too. Like why the hospital was required to come up with only $2 million, when under the department’s own formula, the number should have been about $120,000 higher than that. And given that the hospital has spent $925,000 on recruiting and retaining primary carers, the amount left should be $1.075 million.

Add those figures together, and it appears the amount available for grants should be some $200,000 higher.

This much is clear. In Massachusetts, any health care entity which wishes to build a facility such as a hospital, or to enhance the services it offers with such technologies as MRIs, must spend an amount equal to five per cent of that cost on community benefits.

The capital cost of the Island’s new hospital, according to the minutes of the state’s public health council, which approved the new facility at its meeting on Dec. 20, 2005, was $44,248,575. Five per cent of that is about $2.124 million.

The hospital’s first plan for the expenditure of that money, submitted in July 2004, was rejected by the department’s Determination of Need office, the relevant oversight body.

The subsequent proposal which the hospital submitted contained four elements:

• Between $825,000 and $1,025,000 to compensate the hospital for their cost of recruiting and retaining primary care clinicians;

• $600,000 to underwrite the public health infrastructure of the Island to be administered by the six town boards of health;

• $400,000 to underwrite the provision of mental health services on the Island;

• $100,000 to underwrite services to address emerging needs and new initiatives.

The money was to have been spent over five years.

That plan was approved by the state at the December 2005 meeting. The minutes of that meeting go on to record:

“Funding of the aforementioned initiatives will begin within 30 days following DON [Determination of Need] approval.”

So the money should have started to flow before the end of January 2006, and should have been spent by January 2011.

But no money was spent, and the plan was subsequently substantially changed. The two elements which survived only slightly changed were the money for the hospital’s recruitment and retention initiative and the $100,000 earmarked for “emerging needs and new initiatives,” now termed mini-grants.

The hospital wasted no time on spending the money on itself. In a written response to questions from the Gazette, hospital president and chief executive officer Timothy Walsh said:

“During FY 2006 through FY 2008, $925,000 was credited to the physician recruitment and retention portion of the DON. It should be noted that the hospital spent an additional $1,200,000 on this effort which was not credited to the DON but helped in improving primary care.”

He said five physicians had been hired by the hospital.

Mr. Walsh also noted that on Jan. 23, 2006, an RFP for the behavioral health component was presented to the mental health/substance abuse subcommittee of the Dukes County Health Council, which began working on a response. Over more than a year, consultations expanded to include a number of other parties.

“As the meetings progressed,” Mr. Walsh said, “it became apparent that Community Services would be the only applicant for the RFP.”

Further meetings decided that Community Services, the hospital and state Department of Mental Health “would need to work together,” he said.

Still, nothing concrete happened.

Then, after what one source described as “three years of foot-dragging” by the hospital, last year the Department of Public Health changed its DON guidelines, and the whole process went back to square one.

Since last November, the various parties have been working to refocus priorities.

“To this end,” wrote Mr. Walsh, “the hospital has developed the DON Community Initiatives Planning Group . . . made up of members of the Dukes County Health Council, the health agents from all the towns and the Southeast Center for Healthy Communities.”

The group reviewed data, presented findings to a couple of community forums and now is close to actually spending some money.

Who’s to blame for such an attenuated process? The hospital? State health officials? The Vineyard’s long-observed inclination for procrastination, mediated through committees? There seems enough blame to go around, although it is worth noting the only beneficiary of the long, long process has been the hospital.

The bottom line is that for several years, during a cycle of great economic stress, people in need of help have not received it.

As one individual associated with the process put it this week: “As good as this is that we have now got to this point, it would have been good five years ago too.”