Findings for case studies of state and local immunization programs

Background: As part of its examination of federal support for immunization services during the past decade, the Institute of Medicine (IOM) Committee on Immunization Finance Policies and Practices (IFPP) commissioned eight ca se studies of the states of Alabama, Maine, Michigan, New Jersey, North Car olina, Texas, and Washington; and a two-county study of Los Angeles and San Diego in California. Specifically, the IOM Committee and these studies rev iewed the use of Section 317 grants by the states. Section 317 is a discret ionary grant program that supports vaccine purchase and other immunization- related program activities. These studies afforded the Committee an in-dept h look at local policy choices, the performance of immunization programs, a nd federal and state spending for immunization during the past decade. Methods: The case-study reports were developed through interviews with stat e and local health department officials, including immunization program dir ectors, Medicaid agency staff, budget analysts, and Centers for Disease Con trol and Prevention public health advisors to the jurisdiction. Other sourc es included state and federal administrative records and secondary sources on background factors and state-level trends. The case studies were supplem ented by site visits to Detroit, Houston, Los Angeles, Newark, and San Dieg o. Observations: The nature of immunization "infrastructure" supported by the Section 317 program is shifting from primarily service delivery to a broade r set of roles that puts the public effort at the head of a broad immunizat ion partnership among public health, health financing, and other entities i n both the public and private sectors. The rate and intensity of transition vary across the case-study areas. In the emerging pattern, service deliver y increasingly takes place in the private sector and is related to managed care. "Infrastructure" is moving beyond supporting a core state staff and l ocal health department service delivery to include such activities as immun ization registries, quality improvement, and coordination with programs out side public health agencies. At the same time, the recent decline in federa l Section 317 support is forcing difficult choices between old and new acti vities at the state and local levels. Conclusions: Immunization programs function as an organic component of the local health care financing and delivery systems of which they are a part. Immunization efforts are organized and conducted within distinctive state a nd local fiscal, economic, and health care contexts. Section 317 Financial Assistance grants, while playing a vital role in supporting immunization "i nfrastructure," have been too unstable and unpredictable to elicit the stra tegic planning, programming, and own-source spending that would be optimal for state and local programs. The predominant immunization function of stat e and local public health agencies is becoming assurance of age-appropriate immunization throughout the lifespan. To be successful in this emerging ro le, the health agencies must be supported with appropriate staffing, intera gency collaboration, and clearly articulated authority.