provide support for specific initiatives. For example, 15 states have direct or in-kind state funding for registry development (although the size and length of such funding vary).

Twenty-one states do not fund immunization infrastructure, and four recently redirected state funds from vaccine purchase to infrastructure support. More common across states is indirect support of the immunization program through intergovernmental transfers, involving other state or federal programs or services. In addition, many states provide in-kind contributions in the form of assistance from school nurses and secretaries, who conduct school-based assessments of children’s immunization status, and from local health departments (e.g., facilities and overhead, and locally funded staff who perform multiple duties, including the delivery of immunizations) (Freed et al., 1999). Five states mentioned the contributions of volunteers in conducting various immunization activities.

State Finance Practices

State vaccine purchase grants from CDC remained relatively stable during the 1990s (close to about $130 million per year in the period 1996– 1999; see Table 5–2). Although the VFC program assumed responsibility for distributing large quantities of vaccine directly to providers that immunized disadvantaged children, changes in the vaccine schedule and initial uncertainties about the reliability of the VFC program caused state health officials to stockpile surplus vaccines. Reliance on federal funds for vaccine purchase also allowed some states to use their own revenues for other, more risky investments in community assistance and registry programs. In one year (1995), a significant decrease in state vaccine expenses created a surplus of $60 million in the Section 317 vaccine purchase awards, which CDC transferred to state operations/infrastructure support with congressional approval (information provided by CDC).6

Several factors within each state influence levels of public health investment and administrative systems, including demographics (such as population size and urban/rural distribution), per capita wealth, tax revenues, the size of the uninsured populations, and health care traditions (Marquis and Long, 1997). Finance practices may also be affected by the organizational structure of state health programs. For example, in states such as Maryland and Texas, where Medicaid is located administratively or fiscally within the department of health, state agencies used vaccine purchase savings from the implementation of VFC to increase provider reimbursement fees, or to purchase additional vaccine for school health programs or other groups not covered by VFC. In states where Medicaid is not housed within the department of health, VFC savings were commonly not captured within the immunization program, and sometimes

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