The scale and impact of changes in the immunization schedule, the nature of disease, and the health care delivery system have distinct implications for the efforts of various levels of government to monitor and respond to trends and shifts in immunization coverage. The states, largely through local governmental authorities, have the primary responsibility for ensuring public health and the delivery of health care services for their citizens. Infectious disease control and prevention, however, requires a nationwide effort and if only for this reason constitutes a national interest. In addition, many states require extra assistance to meet the needs of their populations, either because those needs are extraordinary or because state resources are especially limited. Finally, it is essential to acknowledge the legitimacy of state and local variations in the organization and financing of immunization services, as these services must be responsive to local needs, populations, and professional and fiscal resources. National immunization policy is better focused on goals, outcomes, and identification of successful interventions that increase immunization coverage than on “how to” prescriptions.

The changing realities of health care organization, financing, and politics have resulted in a concomitant shift in public health policy and strategy. To meet its protective responsibilities, the public health sector must work with a rapidly changing health care system, first to understand its approach, and then to apply a variety of government tools to fulfill public health objectives. These tools include (1) a regulatory environment that protects the public from dangerous or ineffective vaccines, (2) a new level of surveillance information that not only captures the peaks of epidemics but also identifies individuals who require immunization services, and (3) a quality assurance role that applies health services research and technical assistance in ensuring immunization coverage.

State and local public health agencies are taking on health system management roles and developing tools that can help them work with and through managed care to improve practices, reduce missed opportunities, and ensure timely immunization coverage. At the same time, however, public health agencies at all levels of government must remain prepared to combat disease epidemics and provide vaccines when necessary to underserved groups.

Finding 2–2. The magnitude and complexity of the modern immunization system have significant implications in terms of both cost and records management. Protecting the public’s health requires attention to multiple components of a complex system composed of numerous public and private agencies. Institutional relationships within this system are loose and disjointed, resulting in ambiguous roles and responsi-



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