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Calling the Shots: Immunization Finance Policies and Practices
The selection criteria included coverage rates (as determined by the National Immunization Survey), population size, and the proportion of individuals from racial and ethnic minority groups residing in the core city.
The 11 metropolitan areas were New York City, Philadelphia, Newark, Miami, Chicago, Detroit, Dallas, San Antonio, Houston, Phoenix, and Los Angeles.
The grantee reports used different surrogate measures to identify pockets of need, such as proportion of minorities (25 grantees), population density (21), poverty level (19), provider/service shortage (17), proportion of single-parent households (13), educational status (less than 12 years of education or GED) (12), public assistance rates (10), and vaccine-preventable disease morbidity (9). One-fifth of the grantees also used geographic information systems computer software to identify and map pockets of need. The grantees described seven direct measures for identifying pockets of need: retrospective surveys (29), provider-based surveys (21), local immunization registries (20), cluster surveys (12), birth certificate-based surveys (11), statewide immunization registries (11), and random digit dialing surveys (6). In measuring and monitoring immunization coverage in the pockets of need, grantees reported on population-based methods, provider assessments, and the frequency of measurement. Retrospective school-based surveys were used by 50 percent of the grantees to measure and monitor coverage. Most respondents relied on public clinic assessments (51 of 58 grantees) to monitor coverage rates, although private provider assessments (36) and, more rarely, managed care plan assessments (17) were also used. Assessments were usually conducted annually (69 percent).
Additional strategies reported by the grantees as part of their intensive efforts in pockets-of-need areas included outreach (82.8 percent), provider education (75.9 percent), and linkage with other public assistance programs (36.2 percent). Outreach efforts included public education, community awareness campaigns, coalition building, door-to-door canvassing, use of volunteers, and involvement of community-based organizations to contact families of individuals identified as undervaccinated.
Between 1992 and 1995, CDC awarded nearly all carryover funds in addition to, rather than in lieu of, newly appropriated funds. This compounded the problem in grantee areas that experienced difficulty in expending their funds efficiently. CDC reports that during these years, the NIP was trying to resolve the carryover issue by encouraging states to continue to build and sustain the systems needed to raise immunization coverage levels with new funds, while using the carryover funds for one-time expenses (information provided by CDC).
The amount of funds available for infrastructure services within the Section 317 grants in 1997 and 1998 was less than half of what was appropriated in 1996. See Table 5–6.