proportion of the population served by health department-operated clinics. Fifteen states have adopted universal purchase policies (see Chapter 3); the remainder contribute a relatively small amount of state funds (i.e., less than 30 percent of total public vaccine purchase in the state) or nothing at all to supply vaccines to disadvantaged adults and children.

In 1994, an earlier IOM committee warned state and federal officials that “current approaches to immunizing children are not sufficient to reach the 1996 target of 90 percent coverage” (IOM, 1994b:26). This prediction was borne out: the overall immunization rate for preschool children (aged 19 to 35 months) increased to just 79.2 percent in 1998 (information provided by CDC). The committee’s report states: “To guide the development of new programs and the allocation of funding and other resources, states must have comprehensive information on children’s unmet needs for immunizations and on the factors that keep them from receiving those immunizations” (IOM, 1994b:26). Recognizing that state needs will vary, the report continues:

No single plan will lead to comprehensive immunization coverage in every state. Common themes may exist, but each state must find a solution that takes into account the specific immunization needs of its children and how its providers and organizational resources can be used to meet those needs. The committee is persuaded that solutions will require state collaboration with local health departments, private providers, state and local chapters of providers’ professional organizations, community groups, and others. States should be exploring how to strengthen primary care to meet not only children’s immunization needs but also their other important health care requirements. (IOM, 1994b:27)

In addressing the finance requirements for this enhanced set of efforts, the report notes: “States are expected to apply CDC funds previously spent on vaccine purchase to improving the infrastructure for delivering immunization services” (IOM, 1994b:22).

The present committee’s analysis of budgetary trends, conducted 5 years after that earlier IOM study, suggests that this expectation has not been realized. In many respects, state immunization programs received mixed messages during the 1990s about the delivery of immunization services. On the one hand, the Childhood Immunization Initiative and the early increases in Section 317 funding encouraged the states to rely on their public health clinics to improve access to immunizations by increasing hours of service, availability of walk-in appointments, mobile service units, immunization fairs, and other activities. Many states directed Section 317 infrastructure funds to these areas by supporting additional staff and equipment (Freed et al., 1999).

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