ADVOCACY AND ACTION
Catalyzing Policy Change: Making the Case for Investment
Cervical cancer mortality, disproportionally impacting women in poor countries, is a glaring example of global health inequity. We know why it occurs, who is affected, where most deaths occur, what to do and how to do it. Why are women continuing to die from this disease? Read about our early efforts in Medicine by Model and later progress to link evidence to action in the New York Times.
False Dichotomy: Vaccinate Girls? Screen Women?
While it is reasonable to compare a strategy to provide HPV vaccination to girls and a strategy to provide screening to adult women 3x per lifetime, it is not analytically appropriate to reduce the policy question to an "either-or" choice consisting of only two options. Editorials, such as Introducing HPV Vaccine in Developing Countries - Key Challenges and Issues, represent early efforts to advocate for inclusion of all potential evidence-based options in analyses intended to inform decision-making. We subsequently published more than 25 country and regional analyses (e.g., Kenya, Mozambique, Tanzania, Uganda, and Zimbabwe in East Africa), finding strategies that included both primary and secondary prevention, saved more lives and were more cost-effective than vaccination or screening alone.
Galvanizing Advocacy Efforts in Other Sectors, such as Human Rights
Advocating for implementation of new technologies for screening and for early adoption of HPV vaccination in developing countries required more than peer-reviewed analyses. Important components to catalyzing implementation and policy change included building alliances, fostering cross-disciplinary relationships, creating communication tools, and disseminating research results in effective and creative ways. Editorials and perspectives raised awareness and galvanized efforts in other sectors, such as human rights. For example, the paper "Human Rights in Health Equity: Cervical Cancer and HPV Vaccines" examined the obligations on governments in relation to cervical cancer prevention and HPV vaccines. The author sought to demonstrate that health equity, as an empirical and normative concept, is reflected in the human rights to health and equality under international law.
What Information Do Decision Makers Care About?
While an important dimension of cost-effectiveness analyses is to identify options that provide the greatest health gain, while utilizing resources as efficiently as possible, of equal importance to our country-specific work is the recognition that decision makers prioritize based on attributes beyond benefits and costs—they care about factors such as affordability, feasibility, scalability, equity, and financial protection. Scan examples below.
Limited Human Resources
This analytic framework packages multiple interventions into one contact for cervical cancer screening, taking into account a limited number of health providers. The analysis demonstrated the value of including "real world" barriers beyond the conventional budget constraint of cost-effectiveness analysis.
Inclusion of Disparities
We devised a typology of cancer disparities that considers types of inequalities across different cancers and characteristics important for near-term policy discussions. Using an empirically calibrated cervical cancer model, we identified strategies that are more effective than existing options, are cost-effective, and improve health equity.
Inclusion of Financial Costs
We conducted analyses for international agencies drafting immunization policy recommendations, financing coordination mechanisms, and country decision-makers on the financial costs (i.e., affordability) of the HPV16,18 vaccine, as well as the population benefits, economic costs, and cost-effectiveness (i.e., value).
Rotavirus Versus HPV Vaccination
Immunization policymakers at global and local levels need to establish priorities among new vaccines competing for limited resources. However, comparison of the potential impact of single vaccination programs is challenging, in part due to their different analytic approaches and reporting formats. For example, a cross-sectional comparison of rotavirus and HPV 16,18 vaccination, restricted to a single calendar year, will show that far more deaths are prevented with rotavirus vaccine. However, if the analytic question is framed differently, the results drastically change. We used the photo below to motivate an alternative question. We asked, "If we vaccinate 100,000 children under age 5 against rotavirus how many deaths will be prevented? If we vaccinate 100,000 pre-adolescent girls between ages 9 and 13 against HPV, such as those shown in this photo, how many deaths will be prevented?"
Analytic Approach to Motivate and Enrich Policy Dialogue
We compared the health, economic, and financial consequences of introducing the two vaccines in 72 GAVI-eligible countries using a number of different outcome measures to evaluate affordability, cost-effectiveness, and distributional equity, without restricting outcomes to a single calendar year. We found that with 70% coverage of a single-age cohort of infants and pre-adolescent girls, the lives saved with rotavirus (~274,000) and HPV vaccines (~286,000) are similar; what differs is the timing of the lives saved; rotavirus-attributable deaths occur in close proximity to infection, while HPV-related cancer deaths occur largely after age 30. In fact, 5.2 deaths are averted per 1,000 vaccinated against rotavirus and 12.6 deaths are averted per 1000 vaccinated against HPV 16,18! We leveraged this analysis to motivate a dialogue among international stakeholders and vaccine financing alliances about how we can broaden the policy discussion and enrich our comparison of investment cases by taking into account differences in the timing of the intervention costs and the health benefits.