Introduction of vaccination against HPV for girls

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

The Ministry of Health of Slovenia decided to introduce HPV vaccination for girls aged 11/12 years, corresponding to the age in 6th class of primary schools. The vaccination will be part of the national immunization program and available to all girls. The decision was based on the recommendations of a special commission on HPV vaccination. Financing of the resulting costs for 3 years will have its source on savings from atorvastatin, simvastatin and enalapril, where 7 million ? will be saved.

Recent developments

The present government declared in its coalition contract (treaty) that one of the goals in health care would be the introduction of general reimbursed vaccination against HPV for pre-pubertal girls. This commitment was taken up very seriously since the campaign for the vaccine had been strongly advocated by female MPs from two current coalition parties already in 2007/2008. In that period a voluntary vaccination was set in place and in several municipality mayors or municipal councils decided to sponsor vaccination of girls residing in their respective communities. Endeavours for a reimbursed vaccination available freely to all remained and culminated in the coalition contract.

The MoH in 2008 decided to order three separate evaluations - a scientific evaluation which was carried out by a special commission coordinated by the National Institute of Public Health, an overall assessment and evaluation carried out by the Ministry's advisory body, the Health Council and, finally, an HTA evaluation, which was prepared by a team of experts at the Faculty of Pharmacy. Since all these evaluations provided for positive recommendations, the minister decided to actively search for a feasible option for financing at least the initial phases. Jointly with the Health Insurance Institute of Slovenia (HIIS) they found out the most appropriate way for raising additional funds. It was in negotiating a lower reimbursed price for the three most frequently prescribed medications - atorvastatin, simvastatin and enalapril. This enabled the negotiators to secure sufficient funds for funding vaccination of a single yearly cohort of girls aged 11/12 over the next three years.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

The introduction of vaccination itself is not a unique decision, since it had been taken up by many countries previously to Slovenia. It is in the means of financing that this particular decision is in a way innovative but also specific for the reimbusement and contracting policies in Slovenia.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government: the leading actor in the process

Stakeholder positions

Basically, the main problem with the introduction of the large scale HPV vaccination was in the price of the available vaccines, currently corresponding to 50% of the total collective cost of all other vaccines in the national immunization program. This had for long been a limiting factor. Secondly, strong reserves were expressed in the public health community, since there were strong concerns around negative promotional impacts on the vaccinated cohorts of girls as well as a lack of allocative efficiency. In 2003 the full-scale national screening program for cervical cancer started and is already showing very encouraging results with significant reductions in morbidity and mortality (indices for both are 75, if we take 2006/2003 data). With further effects of the screening programme expected for another 2 to 3 years the figures from 2002/2003 will probably be at least halved, which means that after 2012 less than 20 women a year would die from cervical cancer and less than 100 would develop an invasive type of cervical cancer.

Of course, the overall expectations of the general public, the political arena as well as the clinical setting were in favour of a general vaccination for pre-pubertal girls. This meant that it would only be a question of time before this vaccination were to be introduced. Undoubtedly, the positive recommendation of a special commission co-orrdinated by the National Institute of Public Health - including experts in immunology, virology, gynaecology, pathology, family medicine and prevention - was the most important step in the introduction process.

Actors and positions

Government
Health Insurance Institute of Slovenia	very supportive		strongly opposed
Mutual voluntary insurance companies	very supportive		strongly opposed
'Kala' - NGO promoting HPV vaccination	very supportive		strongly opposed
current    previous

Actors and influence

Government
Health Insurance Institute of Slovenia	very strong		none
Mutual voluntary insurance companies	very strong		none
'Kala' - NGO promoting HPV vaccination	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

The key actor in this process was the MoH and it was also the role of the ministry in influencing the negotiating process with the pharmaceutical industry that was decisive in securing the additional funds. Raising sufficient additional financial resources was a key issue in this policy action, given the extent of the financial crisis, which has reached Slovenia as well. The opportunity to 'raise' 7 million Euros from savings on price levels for atorvastatin, simvastatin and enalapril was rather exceptional and provided for an important source without which it would not be possible to carry out this introduction. Around 75% of the savings will be on the side of the compulsory health insurance and 25% on the side of supplementary health insurance.

Monitoring and evaluation

The policy will have to be monitored and also evaluated in around 3 years from now, given the financial structure of financing for the vaccine. Until that time it is also expected that some of the unknowns regarding the vaccine, the length of its protection and similar will be clarified.

Expected outcome

The important aspect of the introduction of a general vaccination is in securing equity in access to this vaccination. So far, it was limited by the ability to pay of parents and on the decision of some municipalities (most of them richer, in the neighbourhood of Ljubljana) to sponsor vaccination of girls. It will certainly have its effect on reducing the burden of cervical cancer. In any case, linking of the vaccination coverage data and on the vaccination profiles of the vaccinated cohorts with the cancer registry will be vital for a successful monitoring of the ongoing effects on the cohorts exposed to herd immunity through compulsory vaccination.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

In spite of the 'general' opinion about cost efficiency of this policy, it is still questionable to what extent the value added to the existing screening programs will actually be. Of course, from the point of view of the present situation where municipalities and also parents themselves were paying for vaccination of girls out of their own pockets, the system will definitely be much more equitable.

References

Sources of Information

1. Declaration of the MoH of Slovenia regarding the introduction of vaccination against HPV for 11/12 year old girls, presented at a news conference on 27 March 2009; news available in Slovene at: www.mz.gov.si/nc/si/splosno/cns/novica/article/12106/5843/

2. Vaccination of target population groups against HPV - a proposal for the inclusion of HPV vaccination into the 'Programme of immunoprophilaxis and chemoprophilaxis in Slovenia (proposal of the National Commission on HPV vaccination, in Slovene), Ljubljana, November 2007.  

3. Health Technology assessment of the HPV vaccination, Faculty of Pharmacy, University of Ljubljana, October 2008. (in Slovene)

Reform formerly reported in

HPV vaccination policies in Slovenia Process Stages: Policy Paper

Author/s and/or contributors to this survey

Albreht, Tit

Suggested citation for this online article

Albreht, Tit. "Introduction of vaccination against HPV for girls". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/si/a13/1