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Final Observations Institute of Medicine (IOM) report Calling the Shots and the four regional workshops that followed its publication provide a snapshot of current tensions and uncertainties within the national immuniza- tion system. Although states retain the primary responsibility for deter- mining the public health priorities of their communities and developing policies and programs to address those needs, the federal government exercises a profound influence on the quality and scope of state immuni- zation programs. By providing funds, vaccine, personnel, and technical assistance, the National Immunization Program at the Centers for Disease Control and Prevention is a key force in shaping the areas that receive attention within the states and highlighting certain strategies that can achieve national as well as state-level goals. As noted in the IOM report, the repetitive ebb and flow cycles in the distribution of public resources for immunization programs have created instability and uncertainty that impeded project planning at the state and local levels in the late 1990s, and delayed the public benefit of advances in the development of new vaccines for both children and adults (Conclu- sion 1~. Although federal and state governments have important roles to play in reducing this instability, private health care plans and providers are additional partners that have the capacity to do more in implementing immunization surveillance and preventive programs within their health practices. The business sector, which is responsible for purchasing health care benefits for employees and their dependents, is another component 36

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FINAL OBSERVATIONS 37 in the evolving national immunization system whose role has not yet fully developed. Under some circumstances, patchwork efforts and informal collabo- ration can achieve significant results. The growing diversity of health care plans in both the private and public sectors has led to an increasing frag- mentation in the service delivery system and financing strategies for im- munization. Participants in the workshop stressed the importance of ad- dressing this fragmentation through new partnerships that can generate consistent program priorities and performance measures. Such efforts will require additional resources to support routine infrastructure efforts as well as special initiatives. No single agency or program has the capac- ity to do it all, but synergistic efforts have the potential to achieve pro- grams that have greater stability and higher levels of immunization cov- erage, especially in underserved areas.