tem. New and more expensive vaccines were added to the recommended schedule of immunizations. Health care reforms resulted in an increasing reliance on health care providers in the private sector for the delivery of immunization services to disadvantaged populations, accompanied by fundamental changes as a result of the growth of managed care in the larger health care delivery system.

In the wake of these changes, the roles of state and local health departments became more ambiguous and more complex. Their need to provide direct services diminished as private providers and health plans acquired the capacity and resources to deliver primary care services— including immunizations—to disadvantaged groups. However, a new role for public health departments emerged, one that places greater emphasis on performance monitoring and the development of community-level health indicators (IOM, 1996, 1997). This role requires collaboration among multiple sectors to enhance the ability of public agencies to assess immunization coverage rates in samples within small areas and to respond to specific health care needs when the private sector is not able—or not willing—to absorb the costs involved in sustaining high immunization coverage rates among hard-to-reach populations.


In 1998, the U.S. Congress asked IOM to conduct a study of the Section 317 program and of broader questions regarding appropriate levels of effort to achieve national immunization goals. The IOM study committee met during 1999 and 2000 to collect relevant information and to develop a framework to guide its deliberations. As part of this effort, a research team directed by Gary Freed at the University of Michigan conducted a series of structured telephone interviews with immunization program officials in all 50 states regarding the ways in which federal policies and funding patterns during the 1990s influenced the goals, priorities, and activities of state immunization programs (Freed et al., 2000). IOM staff and consultants developed eight case studies of public-sector immunization efforts in the states of Alabama, Maine, Michigan, New Jersey, North Carolina, Texas, and Washington and in San Diego and Los Angeles Counties in California (Fairbrother et al., 2000a).1 Four site visits to Detroit, Newark, Houston, and Los Angeles supplemented the case study materials with discussions with local providers and immunization


Each case study is available electronically via the website of the National Academy Press: www.nap.edu/html/case_studies.

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