monitoring infectious disease outbreaks, vaccine coverage levels, quality of care, and safety concerns. The states differ in the scope and type of public health infrastructure on which they rely to provide both immunization services for disadvantaged individuals and populationwide programs that benefit all citizens within the state.

Some states are better positioned, because of internal administrative arrangements, to use federal funds (e.g., Medicaid, VFC, Section 317 grants, or funds from the newer SCHIP) to support their public health infrastructure. But recent fluctuations in health care programs, reductions in Section 317 grants, and restrictions on the use of federal funds have significantly reduced the ability of many states to develop innovative approaches to program management, data collection, or interactions with private health care providers. Because the Section 317 grants program does not require matching state investments, fiscal incentives for states to share the costs of developing immunization programs that benefit state residents are absent.

The range of per capita contributions among the states is extremely broad: 4 states reported spending more than $10 per capita of their own funds, while the majority of states (31) reported contributions of less than $5 per capita. Only 4 states have direct state funding for a substantial portion (more than 40 percent) of their immunization program infrastructure, and almost half of the states (21) provide no direct state funding for infrastructure needs. When compared with vaccine purchase practices, these estimates indicate a limited commitment within the states to support the public health infrastructure that is required to meet local needs as well as national goals.

Private-Sector Role. The emerging role of the private sector in providing routine medical care for disadvantaged populations requires ongoing attention and oversight to determine whether vulnerable groups are up to date in their immunization coverage. Individual health care providers and health plans have traditionally not been expected to monitor patterns of vaccine coverage or disease within their communities, nor are they currently equipped to assess coverage levels in formats that can facilitate long-term populationwide studies or analysis of local or statewide health patterns.

IMMUNIZATION FINANCE POLICIES AND PRACTICES

Federal funding for state immunization programs underwent a major and rapid rise in response to the 1989–1991 measles epidemic: there was a more than seven-fold increase from $37 million in 1990 to $261 million in 1995. States faced administrative challenges in responding to these initia-



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