rural Texas does not constitute an adequate delivery system for the available vaccines; the higher than expected number of penalties to AFDC participants under Maryland's program to encourage primary care for children appears to reflect difficulties in obtaining timely care (George, 1993); and the overall demand for ambulatory care exceeds the available provider capacity in Los Angeles.

The lack of capacity in the public sector emphasizes that private providers are essential participants in delivering immunization services. Increased federal purchase of vaccines and more CDC grant funding may ease some financial problems, but an inadequate supply of providers may still limit the needed expansion of health care services to provide immunizations.

ESTABLISHING ACCOUNTABILITY AND RESPONSIBILITY

Steps to Take in the Short Term
  • IAPs and state accountability. CDC can help states use Immunization Action Plans (IAPs) to promote state accountability for the immunization status of all children in their jurisdictions. The funding and other assistance associated with IAPs make them valuable tools for influencing the perceptions, expectations, and actions of state officials. A sense of accountability and interest in the success of IAP efforts needs to extend beyond health departments to governors and other senior state officials.

  • IAPs and Vaccines for Children Program. The states can work with CDC to amend IAPs to reflect changes in federal law and the provisions of the Vaccines for Children Program. The IAP program called on states to find better ways to meet the immunization needs of all children. It is the basis for substantial federal support for state immunization efforts but was initiated before adoption of the Vaccines for Children Program. The conjunction of these two programs will give states additional funds and new opportunities to develop effective immunization programs.

  • Primary care and immunization services. States can promote the development of more effective primary care services that will provide children's immunizations. Systematic integration of primary care and immunization services across the public and private sectors is needed. When primary care services are limited, linking immunization services in the public sector with other public services may be helpful. When the need for immunization services is urgent, states should consider locating immunization services with WIC and other public assistance programs or offering immunizations at other nontraditional locations. Special immunization services should not be allowed to divert attention from children's broader primary care needs.



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