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Unresolved Problems and Future ehaIlenses ach of the three prior Institute of Medicine regional workshops in Chicago, Austin, and Los Angeles identified key challenges and ~ unresolved prob-lems that required further attention. The partici- pants in the Washington, DC workshop repeated many of these concerns. INCREASING VACCINE COSTS Workshop participants frequently observed that public and private investments in immunization efforts were easy to justify when the burden of infectious disease was apparent to all. Ironically, the success of the national immunization program in decreasing disease outbreaks and achieving high immunization levels has caused the public to grow com- placent and to question the need to sustain investments in infrastructure programs that support these efforts. Concerns about appropriate meth- ods for distributing the costs of public health infrastructure persist de- spite the willingness of the federal government to assume a larger share of these costs over the past decade. CHANGING PARTNERSHIPS No single agency, public or private, can expect or be expected to solve immunization problems alone. Federal, state, and local health depart- ments traditionally have engaged in constructive partnerships to support the national immunization system and to implement efforts such as out- 33

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34 SETTING THE COURSE reach, reminder/recall, service delivery, public education, and the devel- opment of registry programs. Given the tremendous shift in the delivery site for childhood immunizations over the past decade (from the public to the private sector), new initiatives are required to strengthen collabora- tion with private-sector health care providers, employers, and private health plans in supporting immunization efforts for all populations and, eventually, all age groups. These initiatives require further attention to issues such as the use of immunization measures in quality assessment efforts, the administrative burden associated with private-sector partici- pation in registry development and consumer education, the health care provider's role in assessing immunization status and providing access regardless of the insurance status or income level of the patient, and keeping up with a changing and more complex immunization schedule. Appropriate data and information tools help health care plans and individual providers to improve immunization rates among their pediat- ric and adult patients. But the expenses associated with sustaining these infrastructure elements, especially in pockets of need, require more care- ful planning and financial support if such support efforts are to be sus- tained on a routine basis. Furthermore, the importance of learning from the experience of private providers, who see critical barriers and limita- tions in both public and private financing for the purchase of vaccines and payment for immunization services, should not be overlooked. IMMUNIZATION AND HEALTH SECURITY New concerns about bioterrorism and the rapid emergence of un- known infectious disease are drawing attention to the importance of pub- lic health surveillance and response capacity at all levels of government. Within these discussions, workshop participants in the regional meetings observed that the quality of the immunization system is a fundamental indicator of the integrity and quality of the public health infrastructure. If the nation cannot ensure that the 11,000 children born each day receive the routine immunizations they need, it may not be able to adequately protect the health of all 280 million Americans in times of crisis. Although crisis can stimulate action, sustained efforts are necessary to maintain the public health infrastructure and achieve immunization goals. SIMPLIFYING THE IMMUNIZATION SYSTEM Advances in the discovery, development, and production of vaccines have led to an increasingly complex immunization schedule and greater fragmentation in the vaccine delivery system. Some states have attempted to remove financial barriers to immunization and ease the administrative

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UNRESOLVED PROBLEMS AND FUTURE CHALLENGES . . 35 burden on their health care providers by adopting a universal purchase strategy that is partly financed through state revenues. Others depend on the federal government to meet their vaccine needs, resulting in a patch- work of different eligibility criteria and inventory control requirements within public and private health plans that frustrate both the public and health care providers. Some participants have urged the development of public and private partnerships designed to ease these financial burdens and to simplify vaccine purchasing arrangements while retaining the goal of providing universal access to recommended vaccines. STABLE FUNDING Tighter health care budgets within many states have led to the reduc- tion or elimination of special immunization programs, such as hepatitis B campaigns or outreach efforts within private pediatric practices. Uncer- tain funding for immunization infrastructure has also reduced opportuni- ties for longer term planning and commitments and makes it difficult for the health department to be a good partner in community immunization efforts. Efforts to sustain improvements in areas such as disease surveil- lance and public health laboratories may benefit from new funds associ- ated with bioterrorism initiatives, but the scope and allocation of such funding is not yet certain. Experience with programs such as Vaccines for Children and the State Child Health Insurance Program has demonstrated that stable and predictable funding streams can lead to significant im- provements in immunization levels, but other approaches are still needed to benefit the children who are hardest to reach. As one participant ob- served, in the Los Angeles workshop, public health is invisible when it works because people do not get sick. The persistent convergence of re- curring problems such as unstable funding, rising vaccine prices, and vaccine shortages could create conditions that will eventually contribute to disease outbreaks. Legislative initiatives at both the national and state levels will be required to address these concerns through enhanced re- sources and stable funding strategies.