IMMUNIZATION

The Use of Vaccinations for Children

The Use of Vaccinations for Children

Introduction

American culture, institutions, and politics impose a strong bias against viewing public problems as management challenges. The history of public management is one of perverse political and institutional incentives which provide consistent discouragement to building a case for management or for viewing public problems as cases of public management or implementation failure. The Clinton Administration entered office with a broad policy agenda. Policy is what captures the public imagination. But while policy may fuel the public's demand for change, it is overemphasized and overused as a vehicle to improve the performance of governmental organizations. Much of the disappointing outcome of public activities derives as much from an absence of adequate attention to issues of program management and service delivery as they do from misguided public policy choices. Indeed, public policy more often than not develops at the implementation stage when field conditions can shape or subvert initial policy designs developed in advance (Levin and Sanger, 1994).

Policy choices are fundamental. As we have argued elsewhere, a policy choice is a point decision “that involves a self effectuating choice among competing alternatives; a line decision is one that requires the coordination by plans of action of many people over a substantial period of time” (Wilson, no date). Point decisions are shaped by ideas; by contrast line decisions are mostly shaped by organizational or situational resources and how they are assembled. Assemblage is the essence of a line decision and is the essential difficulty facing public executives. It is the process following the formulation and adoption of an initial policy mandate.

We are distinguishing here between policy and management - between point and line, between policy goals and the means to realize a policy. While in reality the temporal sequence may not be as clear as we suggest (since policy is often developed through the program implementation process), there is an important analytical distinction here between enunciating a new policy as a solution to a problem and diagnosing and treating the problem as one of failed management. Further, even when policy solutions are indicated, they need to be followed by a carefully engineered process of program assembly, and this is an interactive process. We argue here that both a failure to see the problem of low immunization rates among young children as a management and service delivery problem and the related failure to attend to the centrality of management after the policy was designed is a more generalized problem of American governance.

The analysis that follows seeks to evaluate the reasons for the poor fit between the diagnosis of the problem of existing childhood immunization policy and the ultimate policy prescription of the Clinton Administration which relies almost exclusively on reducing the price of vaccines. This was the case even though an abundance of research demonstrates the small role that vaccine prices play in explaining disappointing rates of vaccination among young children and the more than ample supply of free vaccine that is currently available for ...