coverage, and the performance of immunization policy and leadership roles within their communities. The public clinics were able to draw on patient revenues for specific services to help finance multiple types of public health activities.

The emphasis on providing vaccines as a fundamental part of primary health care in the private sector and the creation of the VFC program separated these roles. Vaccine purchase and service-delivery responsibilities were shifted largely to the private sector (although many public clinics continue to immunize children under Medicaid contracts and other service arrangements to meet the needs of children in local communities who do not qualify for federal assistance). Public health agencies were expected to sustain their traditional prevention and measurement efforts, while also assuming new responsibilities for administering the VFC program by enrolling private providers and monitoring a much larger set of immunization records. The policy role of public health agencies was thus expanded to include encouragement and oversight of private-sector performance in meeting national immunization goals; however, the VFC program did not provide the additional administrative resources that would enable the exercise of these functions at the local level.

This redefinition of roles and responsibilities occurred during a time when federal resources for state immunization infrastructure efforts were diminishing, and greater reliance was being placed on the states and the private sector to meet national health needs. States took on new responsibilities for the health care of infants and children through programs such as the State Children’s Health Insurance Program (SCHIP), for example, which provided greater opportunity to work with managed care organizations in providing primary health care services (including immunizations) for Medicaid families.

These transitions and shifts in roles and responsibilities have resulted in ambiguity with regard to leadership, measurement, and finance responsibilities for the national immunization system. Resolving this ambiguity will require careful consideration of the level of oversight and resources necessary to ensure that the private and public health sectors can each contribute effectively in addressing national immunization needs. The new system of private-sector responsibility for clients who were once served by public health clinics is still evolving, and an array of issues is emerging that requires careful consideration before judgments are made about the successes or limitations of this new approach. In this context, the following sections review in turn the immunization roles and responsibilities and associated finance policies and practices of the private sector, local health departments, the states, and the federal government.

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