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AN EXTENDED COST-EFFECTIVENESS ANALYSIS OF PUBLICLY FINANCED HPV VACCINATION TO PREVENT CERVICAL CANCER IN CHINA

Monday, 8th of June 2015

AN EXTENDED COST-EFFECTIVENESS ANALYSIS OF PUBLICLY FINANCED HPV VACCINATION TO PREVENT CERVICAL CANCER IN CHINA

Vaccine

Volume 33, Issue 24, 4 June 2015, Pages 2830–2841

Excerpts below; full text is at http://www.sciencedirect.com/science/article/pii/S0264410X15002418

• Carol E. Levin^a, , , Monisha Sharma^b, Zachary Olson^a, Stéphane Verguet^c, Ju-Fang Shi^d, 

Shao-Ming Wang^d, You-Lin Qiao^d, Dean T. Jamison^a, Jane J. Kim^e

• ^a Department of Global Health, University of Washington, Seattle, United States
• ^b Department of Epidemiology, University of Washington, Seattle, United States
• ^c Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
• ^d National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
• ^e Center for Health Decision Science, Department of Health Policy Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States

Received 20 May 2014, Revised 13 February 2015, Accepted 18 February 2015, Available online 12 March 2015

Abstract

Introduction

Cervical cancer screening and existing health insurance schemes in China fall short of reaching women with prevention and treatment services, especially in rural areas where the disease burden is greatest. We conducted an extended cost-effectiveness analysis (ECEA) to evaluate public financing of HPV vaccination to prevent cervical cancer, adding new dimensions to conventional cost-effectiveness analysis through an explicit inclusion of equity and impact on financial risk protection.

Methods

We synthesized available epidemiological, clinical, and economic data from China using an individual-based Monte Carlo simulation model of cervical cancer to estimate the distribution of deaths averted by income quintile, comparing vaccination plus screening against current practice. We also estimated reductions in cervical cancer incidence, net costs to the government (HPV vaccination costs minus cervical cancer treatment costs averted), and patient cost savings, as well as the incremental government health care costs per death averted.

Results

HPV vaccination is cost-effective across all income groups when the cost is less than US $50 per vaccinated girl. Compared to screening alone, adding preadolescent HPV vaccination followed by cervical cancer screening in adulthood could reduce cancer by 44 percent across all income groups, while providing relatively higher financial protection to the poorest women. The absolute numbers of cervical cancer deaths averted and the financial risk protection from HPV vaccination are highest among women in the lowest quintile; women in the bottom income quintiles received higher benefits than those in the upper wealth quintiles. Patient cost savings represent a large proportion of poor womens average per capita income, reaching 60 percent among women in the bottom income quintile and declining to 15 percent among women in the wealthiest quintile.

1. Introduction

Cervical cancer is one of the most common diseases affecting women in China. While average national estimates are low, cervical cancer burden may be underestimated, as human papillomavirus (HPV) prevalence is high. Cervical cancer mortality is heterogeneous across geographic settings; and highest among poor women in Gansu, Shanxi, and Shaanxi, the least developed provinces in central and western China.

The low national cervical cancer estimates may be the result of the lack of a nationwide cancer registry. Most registries are located in urban areas, where the socioeconomic status of women is higher and cancer disease burden is likely lower than rural areas [1]. While HPV prevalence has been found to be similar in rural and urban regions, cervical cancer mortality is significantly higher in rural areas. This disproportionate burden is likely attributable to unequal availability and utilization of health services including screening and treatment.

In the absence of a national cervical cancer-screening program in China, screening is opportunistic. From 2009 to 2011, the Chinese government initiated a program to provide free cervical cancer screening for 10 million rural women between 35 and 59 years of age which covered only 7% of women due to shortages of gynecologists and cytologists and an overburdened health care system [2] and [3]. With an estimated 700 million women in China, scaling up preventative services is formidable [4], [5], [6] and [7].

Chinas health care system has been evolving to respond to the pervasive unequal access to health services. In 2009, China began to introduce universal health coverage [8], reaching high coverage in urban and rural areas with two government-sponsored schemes. Despite high coverage, reimbursement is limited to inpatient expenses. It is unclear how recent health insurance schemes have impacted womens cervical cancer treatment rates; however, recent studies indicate that services are not reaching poorer women [1], [5] and [9]. This trend is likely to continue until insurance schemes cover outpatient services.

While widespread screening with cytology has dramatically reduced the cervical cancer burden in developed countries, low-resource settings lack the infrastructure and resources to achieve similar cancer reductions. Newer screening technologies that are cheaper, cost-effective and easier to implement than cytology can reduce the cervical cancer burden among Chinese women, protecting them from future costs and consequences of the disease [4], [10], [11], [12] and [13].

HPV vaccination is a promising primary prevention strategy against cervical cancer. Studies indicate that screening women and vaccinating preadolescent girls against HPV is cost-effective in reducing the burden of cervical cancer in China [10], [11], [14] and [15]. Vaccination strategies were cost-effective up to US$55 per vaccinated girl, with incremental cost-effectiveness ratios (ICER) of US$2746 per life year saved (LYS) when vaccination was combined with screening once in a lifetime, and up to US$5963 per LYS when combined with screening five times in a lifetime [14]. At, US$25 per vaccinated girl the ICER declines to US$1360 per LYS.

Recent attention to reaching the goal of universal health coverage (UHC) provides strong rationale for exploring mechanisms to expand access to cervical cancer prevention and treatment in China without increasing financial burden of women seeking care [16]. We sought to apply an extended cost-effectiveness analysis (ECEA) methodology [17], [18] and [49] to evaluate public financing of HPV vaccination for cervical cancer prevention. Recent theoretical and empirical work provides guidance in this area; either focused on applications for high-income countries or limited to a few infectious disease conditions in a number of low- and middle-income countries [19], [20] and [21]. In this application, ECEA adds new dimensions to conventional cost-effectiveness analysis (CEA) through a more explicit treatment of equity and impact on financial risk protection (prevention of medical impoverishment) [17]. Specifically, ECEA can evaluate publicly financed programs by measuring program impact along four main dimensions: (i) health benefits; (ii) household private expenditures averted (“household cost savings”); (iii) financial risk protection provided to households; and (iv) distributional consequences across the wealth strata of country populations. As a result, ECEA enables quantitative inclusion of information on equity and amount of financial risk protection bought per dollar expenditure on health policy, in addition to amount of health bought [17].

Consequently, the distribution of health and financial benefits resulting from interventions—and by extension from the policy instruments that finance them—can be examined to determine whether they are pro-poor. In practice, ECEAs can also be used to examine financial effects of interventions and policies on individuals or families by income group and in aggregate. Health policies and interventions typically involve costs to the public sector and households. Even if an intervention is provided at no cost, users often incur time costs to travel or wait at a health facility; value placed on these costs differs according to income level.

Publicly financed health interventions can help users to avoid future costs; for example, HPV vaccination and cancer screening programs reduce the cervical cancer risk, which might otherwise lead to medical impoverishment (related to expensive medical bills for cancer treatments), devastating health consequences (e.g. death of a mother, which increases the mortality risk for children), or both.

We evaluated the consequences of full public finance of HPV vaccination in China using ECEA methodology. Public finance increases HPV vaccination uptake, leading to important health gains and can reduce household medical expenditures. Finally, public finance can have differential impacts among populations of different income levels. We estimated the level and distribution (across income groups) of the cervical cancer deaths averted; the households expenditures related to cervical cancer treatment averted and the costs needed to sustain the HPV program; and financial risk protection, using a combination of indicators, detailed below.

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