Dr. Freed noted that variations in the levels of state investments in immunization program operations and infrastructure exist, with these variations reflecting factors such as the state’s child population and the state’s organization of immunization services. Overall, Dr. Freed noted, about half of the states provide no funding for immunization infrastructure. States that fund public clinics for the delivery of immunization services may require larger budgets for immunization infrastructure than states that primarily rely on private providers. Immunization programs in some states also benefit from in-kind support provided by other state agencies, such as the education department if school personnel are responsible for assessing the immunization status of children entering school.

State officials reported seeing CDC as a key partner in immunization activities. State priorities, however, were not necessarily consistent with those established by CDC in conjunction with Section 317 program grants for the immunization infrastructure. In rural states, for example, CDC’s emphasis on “pockets of need”—areas with especially low immunization rates, often in inner cities—is less relevant. Because states rely heavily on CDC funding for their immunization infrastructure support, the influx of funding in the early 1990s was welcome, but subsequent reductions have forced states to reevaluate their program priorities and often to reduce services. Some states, for example, have had to reduce staff and operating hours at immunization clinics or reduce efforts to support connections with Special Supplemental Food Program for Women, Infants, and Children (WIC) clinics.

Section 317 program funding for immunization program infrastructure was reduced in the mid-1990s in part because many states were not able to spend their grants in a timely fashion. The interviews with state immunization program officials revealed that various administrative obstacles had contributed to this problem. On the federal side, the program required that grant funds be used within the grant year, but awards were often delayed and the federal government could give no assurances regarding future funding. Without assurances of stable and sustained funding, states were frequently reluctant about or even prohibited from hiring new staff or undertaking multiyear projects, such as immunization registry development. In states like Texas with a 2-year legislative and budget cycle, immunization programs had no way to adjust their budgets to make use of the additional funding. Dr. Freed also observed that term limits for state legislators pose a challenge for immunization programs. New legislators may be uninformed about immunization issues. Furthermore, it can be difficult for legislators to see either the positive or the negative effects of funding decisions during their time in office because it may take two or three legislative sessions for the effects to become evident.

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