2ndMalaysian Postgraduate Conference (MPC2012) 7-9 July, Bond University, Gold Coast, Queensland, Australia Editors: M.M. Noor, M.M. Rahman and J. Ismail
NATIONAL HPV VACCINE: THE AUSTRALIAN DEBATE Faiz Daud 1
Department of Community Health, UKM Medical Centre, Cheras, Malaysia 2 School of Public Health, University of Sydney, Australia Email:
[email protected]
ABSTRACT The purpose of this paper is to analyse the public health policy with regards to the Human Papilloma Virus (HPV) Vaccination Programme in Australia. A case study based on media reports and journal articles was used to examine the public health policy which evolves around the framework of policy triangle. The environmental factors influencing the policy context; PBAC, politicians, health professionals, pharmaceutical industries, consumer groups, individuals and the media that leads to the variation in policy. Several actors with authority and external forces were identified to have direct and indirect impact on the HPV vaccine policies which intervene with the costeffectiveness assessments, the independence of the process and political intervention in the decision making. It involves a complex process influenced by multiple factors such as politics, socio-economic and other environmental factors that are elaborated based on context, process and content. In spite of having a well defined process, there are some weaknesses in the decision making process that is not well understood by the affected stakeholders thus posing a threat to the independence of the system. Keyword: Public health, HPV, Vaccine policy INTRODUCTION Public health policy evolves around the framework of policy triangle (Kent et al., 2005) which involves a complex process influenced by multiple factors such as politics, socioeconomic and other environmental factors. The environmental factors influence the policy context that leads to the variation in policy which has profound impact in our Human Papilloma Virus (HPV) case study in Australia. Several actors with authority and external forces were identified to have direct and indirect impact on the HPV vaccine policy which will be discussed based on the context, process and content. CONTEXTUAL FACTORS THAT INFLUENCE THE HPV VACCINE POLICY Situational Factors Strong political statement was made by the then Prime Minister (John Howard) on Australia Day, the 26th January 2006, when awarding Ian Frazer the Australian of the Year. Roughead and Gilbert (2008) made a public statement that the vaccine would be made available to young women across Australia. The statement was made prior to consultation with the Federal Health Minister (Tony Abbott). This is seen as a political mileage for the ruling party as it spurs opportunity for the general public to participate in policy discussion and decision as the federal elections was just around the corner. 11
National HPV Vaccine: The Australian Debate
Structural factors Media in Australia play a big role in influencing the general public. Within a short period after the vaccine was launched, media coverage of the new vaccine portrayed the vaccine as a medical miracle, a life saver and framed as social good. This stimulated public debate and expert opinions were reported in favour of the vaccine to be made available to the public free of charge. Experts such as Associate Professor Margaret Davy who is the Royal Adelaide Hospital’s Director of gynaecological oncology was quoted as saying that the government appeared to be saying that it was not worth to spend AUD450 on women. Statement by not so independent expert, Dr Gerry Wain who was not only the Westmead Hospital gynaecology director but also NSW cervical screening program scientific director, pointed out that the government does not value the life of Australian women especially young, poor women who cannot afford to buy the vaccine but needed it most. These comments cemented the pressure on the government to reverse the initial decision by the Pharmaceutical Benefits Advisory Committee (PBAC). There were also disappointment expressed by non-governmental organization, Cancer Council, consumers and doctors’ groups when PBAC rejected the vaccine application. These parties form a strong voice in advocating for the HPV vaccine approval. Cultural factors As the vaccine was to be given to young girls aged 12-13 years, it caused a strong feeling of anxiety among conservative religious groups (Colgrove, 2006) in the society as it was seen as encouraging the girls to have sex at a younger age as they were deemed “protected”. The idea that it may spread wrong message that vaccinated girls were “protected” from sexual transmitted diseases also arose. Mr Tony Abbott was also criticised for his defence of PBAC rejecting the HPV vaccine on the basis that his Christian values were limiting his ability to make the vaccine readily available to all women. However, these issues were short-lived as the Federal Government went ahead in making the HPV vaccination a school based vaccination programme. It was also made available through local GPs in community base catch-up programmes where older women up to 26 years of age can also receive the vaccine. International factors Ian Fraser being awarded Australian of the Year accolade was a gesture of national pride. It proves that Australia is in the forefront of medical advancement as it was the first of its kind and by implementing the HPV vaccination programme would make Australia be seen as “leading the world” and promoting international recognition.
PROCESSES THAT INFLUENCE THE HPV VACCINE POLICY Problem Identification The prevalence of HPV among cervical cancers was around 75% and the breakthrough in having a vaccine was welcome news for many parties. In 2005, press articles reported HPV vaccine was termed as the world’s biggest vaccine following reports that results 12
Faiz Daud/ 2ndMalaysian Postgraduate Conference, 7-9 July 2012, Queensland, Australia Page 11-14
from phase III clinical trial: “Medical miracles Aussie doctors unveil cervical cancer lifesaver”. Therefore, it was worth making HPV vaccine a national priority by the Federal Government as it coincides with the upcoming general elections. Policy Formulation PBAC plays a role in providing evidence based on several criteria. They also make recommendations which were supposed to be independent of external pressure. However, the process was interrupted by political intervention. Pressure was also mounted from CSL as they try to push for the highest profit before a rival product was ready. Pressure from the Prime Minister and women health groups forced PBAC to call for an Extraordinary Meeting and subsequently in less than a week, the HPV vaccine was made available via government funding. Policy Implementation Once the HPV vaccine was approved, the government implemented a school based programme where school girls’ age 12-13 years will receive the full three doses. Parental consent was required for each student and injections were carried out in schools. The HPV vaccinations also include a catch-up programme that aimed at targeting school girls from the age of 14-18 years at the end of 2008. Community based catch-up programme also included older women up to 26 years old to be taken at their local GP. Policy Evaluation Monitoring and evaluation of the programme was conducted in the same setting at the state and national level covering the schools as well as GP/community based programmes. CONTENT THAT INFLUENCES THE HPV VACCINE POLICY Although there was not enough epidemiological data on HPV prevalence/vaccination in Australia, the programme was carried out with the assumptions that international data can be generalized to the Australian population. Its safety and the need for a booster dose remain questionable. Despite all of these, the vaccine was still approved to be used in both boys and girls before sexual onset in an effort to reduce the rate of cervical cancer. The HPV vaccination programme was given only to girls’ aged 12-13 years with the assumption that they have not had sexual contact. The cost effectiveness of the programme remains unclear as the length of immunity offered was not actually known. Nevertheless, the issue of cost was silenced as the bigger picture of “saving lives” was paramount in the society at large coupled with frenzied positive media reports. CONCLUSIONS In spite of having a well-defined process, the HPV vaccination programme in Australia was implemented in haste. There were flaws in the decision making process that was not well understood by the affected stakeholders. Threats to the independence of
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National HPV Vaccine: The Australian Debate
decision making process need to be outlined and mitigated as part of efforts for better communication among the stakeholders, and thus results in better policies. ACKNOWLEDGEMENT The financial support by Universiti Kebangsaan Malaysia (UKM) and University of Sydney, Australia are gratefully acknowledged. REFERENCES AGDHA (Australian Government Department of Health and Ageing). 2006. Press release: Tony Abbot MHR: Government funds Gardasil. Australian Government Department of Health and Ageing. Colgrove, J. 2006. The Ethics and Politics of Compulsory HPV Vaccination. Journal of Medicine, 355(23), 2389-2391. Dunlevy, S. 2006. Cancer’s costly frontline fight, Daily Telegraph, Sydney, 9 Kent, B., Nicolas, M. and Gill, W. 2005. The health policy framework: context, process and actors Chapter 1, In Making Health Policy (1st ed), Open University Press, pp. 4-18 Roughead, E.E., Gilbert, A.L. and Vitry, A.I. 2008. The Australian funding debate on quadrivalent HPV vaccine: A case study for the national pharmaceutical policy, Health Policy, 88, 250–257. Walker, J. and Wardill S. 2006. State may help fund fight against cancer-calls for universal vaccine. Brisbane Courier, Brisbane, 26.
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