and San Antonio, Texas; New York City, New York; Chicago, Illinois; and Philadelphia, Pennsylvania).4

The basic responsibility for public health is at the state level, but states differ in the ways in which they administer local public health programs. Some states rely entirely on state employees for local services. Others delegate their responsibilities to county or local health departments that must rely upon local revenues to supplement state resources. In some metropolitan areas, local health departments are larger than the entire public health staff of smaller or more rural states. Some states have highly centralized data collection efforts used to monitor disease outbreaks and vaccination coverage status, while others have only the results of scattered studies within local health departments that can afford to conduct them. Similarly, some states use their own or federal funds to support programs such as Women, Infants, and Children (WIC) linkages or outreach efforts to improve local coverage levels, while such initiatives are supported entirely with local funds in a limited number of jurisdictions.

Infrastructure Investments and Immunization Programs

Prior to the expansion of the Section 317 program in the early 1990s, most local health departments served primarily as providers of immunizations. Only a handful of state agencies were actively involved in data collection, coverage assessment, or partnership initiatives. With the increase in Section 317 funding in the early 1990s and legislative changes that allowed the federal government to support direct services within the states, funds became available for local immunization programs, extensive experimentation with new measurement efforts, and the formation of new public and private partnerships.

According to an informal survey conducted by the National Association of City and County Health Officials (NACCHO), in the early 1990s local health departments used Section 317 funds to develop new immunization programs in such areas as increased assessment, outreach, performance measurement, program linkages, and information management (NACCHO, 1999). Staff time and clinic hours devoted to immunization activities increased in urban areas, and health clinics were established in rural areas and isolated communities to improve access to immunization services. Evening, weekend, and satellite clinics, specialty clinics (hepatitis B and school-based clinics), and partnerships with other organizations such as WIC and Head Start were developed to target hard-to-reach populations. Local health departments also used federal funds to send staff to health fairs, strengthen advertising and public information campaigns, and improve tracking and recall systems used to survey at-risk populations. Incentive programs for patients were established, and staff training



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