these groups with immunization services and to sustain that connection over time. Financing that effort is expensive, and pay-offs may be small in terms of absolute numbers of individuals who are brought up to date in immunization coverage. Yet even small improvements in immunization coverage in high-risk areas have broad positive impacts within the general community, since they reduce the risk of outbreaks (and the costs of hospitalization or injury that may result), improve general health status, and demonstrate improvements in the quality of health care services within a selected region.

Third, the level of resources required for each state to perform each role effectively is not well understood, since immunization coverage rates are influenced by a broad mix of factors that include national health trends, local demographics and social conditions, and public and private health finance patterns. For example, some states (e.g., Alabama) rely heavily on public health clinics to immunize more than 80 percent of their disadvantaged populations. Such states may spend large amounts on vaccine purchase and direct services and invest little effort in assessing rates of immunization coverage among private providers because vulnerable groups are served directly by the public health system. In contrast, states (e.g., New Jersey) that rely primarily on private managed care plans to supply vaccines to Medicaid clients or other at-risk groups may spend less on direct services, but need to create incentives, regulations, or performance measures that establish accountability within the private health sector for achieving high levels of immunization coverage.

The complexity of the national immunization system should not discourage efforts to address the finance policies and practices that can ensure high levels of performance and direct resources to areas of need. Achieving consistency of effort in both service delivery and assessment of performance and coverage patterns is especially important, because history has demonstrated that when levels of protection begin to decline, disease outbreak occurs, and remedial action becomes necessary (NVAC, 1991). As noted earlier, unprotected sectors can unexpectedly become sources of infectious disease outbreaks and can serve as hosts to preventable pathogens such as pertussis. These lapses in public health preparedness have tremendous negative impacts involving loss of life, preventable morbidity, and financial cost. A strong and vigilant infrastructure is necessary to sustain coverage rates in the face of the changes in science, social conditions, and health care systems discussed above.

STUDY APPROACH

To respond to the six questions listed above, IOM formed the Committee on Immunization Finance Policies and Practices in December 1998.



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