Introduction: Cervical cancer is a major cause of deaths in female in low- and middle-income countries. The disease is preventable by introducing screening tests such as Pap smears, visual inspection with acetic acid (VIA) and HPV DNA testing. Recently, the first vaccine against human papillomavirus (HPV) was introduced to the health care market though the high cost of the vaccine makes it unaffordable especially in resource-poor settings. As of July 2009, the Thai government had not provided universal access to HPV vaccination. This study aims to shed light on the processes by which national HPV vaccination policy in Thailand has developed, with the focus on the role of scientific evidence, including health technology assessment information, in policy decisions.
Methods: Qualitative approaches including documentary review, in-depth interviews, personal communication, direct participation in the policy-related events by the researchers, and brainstorming workshops among key stakeholders were deployed in this study. This research focuses on the development of HPV vaccination policy at the national level in Thailand during the period January 2006 to July 2009.
Results: In Thailand, the responsible relevant bodies regarding this policy process are the National Vaccine Committee (NVC), with technical support from its Advisory Committee on Immunization Practice (ACIP), the expanded program on immunization (EPI), the Department of Disease Control, the Ministry of Public Health (MoPH), the National Health Security Office, the Bureau of Budget, the cabinet and the Thai parliament. The issues under consideration include: the magnitude of the disease prevented by the vaccine, vaccine safety and efficacy, cost-benefit and cost-effectiveness compared to other interventions, budget implications, vaccine delivery, and acceptance of the vaccine among the public. As of July 2009 the ACIP and the NVC had never included the issue of HPV vaccination in the EPI on its meeting agenda. At the same time, the MoPH publicly maintained that universal HPV vaccination could not be provided, owing to the unaffordable vaccine costs.
It was also found that Thai experts including clinicians possessed different positions towards a nationwide introduction of the HPV vaccination and expressed their opinions in academic conferences and public education events. Another important group, policy researchers at two semi-autonomous research institutes in the MoPH, were key participants in the Thai HPV vaccination policy. From late 2007, they presented their study findings addressing the inadequate performance of cervical cancer screening services in Thailand, and the value for money of different policy options for the prevention and control of cervical cancer. They indicated that screening services were cost-saving in comparison to treatment, and that HPV vaccination is costineffective owing to the very high price of the vaccine. This study reaffirmed the government’s position not to fund the immunization program, and was used to encourage the improvement of the screening programs.
The vaccine industry was among several sources of information concerning HPV vaccinations obtained by government officials, experts and professionals. The information includes the vaccine’s effectiveness, safety, doses and administration, precautions, warnings and costs were disseminated through academic conferences and public events. This new intervention had been publicized through the mass media before being licensed in Thailand. However, the campaigns did not lead to any social mobilization that supported public immunization program. Furthermore, despite reductions of vaccine prices offered by the industry in early 2009, an unclear position on a preferable price from policy makers remains. The role of health technology assessment evidence in decision making : the case of human papillomavirus vaccination policy in Thailand v
Conclusions: HPV vaccination policy in Thailand has been largely driven by the unaffordable prices of vaccine products and associated implications for health expenditure. Although domestic HTA information including health economic data of this newly-emerging intervention had been available, such evidence played a limited role in the making of HPV vaccination policy. However, the high prices and existing cost-effectiveness studies of the vaccine drew significant attention from policymakers and health officials to the issues of cervical cancer prevention and resulted in the efforts to improve the existing screening services.