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E,eou~ive Summary [though not always apparent, the need to maintain a quality infra- structure in support of immunization goals remains a high priority across the nation. Developing a plan to determine how the costs of this effort should be allocated across the federal, state, and private health agencies is a significant challenge, especially during times of declining budgets and competing demands on public health resources. The annual costs of achieving high levels of immunization coverage for children and adults in the United States on a routine basis are signifi- cant, exceeding more than $120 million for infrastructure and program support alone. These investments support diverse efforts within the Cen- ters for Disease Control and Prevention (CDC) and state health depart- ments supplemental purchases and administration of vaccines for dis- advantaged populations; routine monitoring and surveillance efforts; and special national, state, and local initiatives designed to improve levels of immunization coverage among difficult-to-reach populations. Although children are the traditional focus of the national immunization system, the availability of vaccines to protect adolescents and adults requires in- novative approaches and new strategies. Yet persistent financing chal- lenges impede efforts to assure that vaccines are available to all who need them. Federal and state governments have developed a national partner- ship for immunization. In recent years, the multiple finance arrangements that support this partnership have become unpredictable. In 2000, the Institute of Medicine (IOM) produced a report Calling the Shots: Immuniza-

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2 SETTING THE COURSE lion Finance Policies and Practices (IOM, 2000a) that illustrated the uncer- tainties and instability of the public health infrastructure that supports U.S. immunization programs. The IOM report proposed several strate- gies to address these concerns and to strengthen the immunization infra- structure. In March 2002, a group of 50 health officials, public health experts, health care providers, health plan representatives, health care purchasers, and community leaders met at The National Academies in Washington, DC to explore the implications of the IOM findings and recommendations for the federal and state governments. Private health plans and business- sector representatives also participated in the meeting to discuss their role in fostering high levels of immunization coverage. The one-day work- shop was the fourth and last in a series of meetings organized by IOM with support from the CDC to foster informed discussions about future financing strategies for immunization and the public health infrastruc- ture. This report of the Washington, DC workshop summarizes the find- ings of the IOM study, reviews the implementation of the IOM recom- mendations, and highlights continuing immunization finance challenges for the nation as a whole as well as state and local health departments. The participants identified strategies to preserve and support traditional public health efforts such as outreach, education, and monitoring and surveillance, and also examined the new demands on the immunization system associated with delivering a higher proportion of vaccines in the private health sector. The stresses and tensions associated with the shift in immunization service settings raised new concerns about the roles of public health departments and the manner in which those roles should be financed. The special difficulties of the public health system in maintain- ing vigilance when visible signs of infectious disease outbreaks are not apparent received much attention.