Figure 1 depicts our main findings using the framework. We present findings in the following four sections of text: context, actors, policy process themes, and policy content.

Fig. 1

Health policy triangle framework: summary of findings

Context

To facilitate understanding of the policy environment, we categorized contextual factors as ‘situational,’ ‘structural,’ ‘cultural,’ and ‘international’ because any nation's public policies can be explained by these factors [22]. After the transfer of sovereignty over Hong Kong from Britain to China in 1997, the city became an autonomous Special Administrative Region of the People's Republic of China, with one exception: defense and foreign affairs remained under a framework known as “one country, two systems” and the Basic Law is its constitutional source of authority [23].

Situational factors are those transient or idiosyncratic conditions sometimes called ‘focusing events.’ The Pharmacy and Poison Board of Hong Kong approved the new nonavalent HPV vaccine to cover more virus types in early 2016. The other focusing event was the once-only occurrence of government transition in Year 2016 and 2017—from the Chief Executive Leung Chun-ying to Carrie Lam. This may have influenced the way authorities put policy proposals on the agenda.

A Chief Executive and an Executive Council lead Hong Kong’s government. The Legislative Council is the law-making body, and in it the Democratic Alliance for the Betterment and Progress of Hong Kong is the largest party. The Food and Health Bureau formulates policies and carries out decisions in health care system. The Department of Health is the Government's health adviser and executing agency for health policies and statutory functions. A well-functioning health care system, including school-based vaccination infrastructure and a drug evaluation mechanism, demonstrates Hong Kong’s government’s capacity; it enjoys confidence of the public. Hong Kong benefited from its political stability in 20 years from 1997 to 2018 and is a society with high level of free-market economic development and great participation of civil society organizations.

Cultural factors include a mix of Chinese and Western values emanating from long-term influence of the West and public acceptance of immunizations as preventive measures. The attitude about sexual issues is conservative because Chinese culture in this population includes deeply rooted Confucianism [24].

International influence means a majority of stakeholders have drawn on successful experiences of developed countries such as the United Kingdom and Australia that enjoy similar economic prosperity. Although few areas or countries in Asia have universal coverage, Hong Kong’s geographical characteristics explain the special attention to Macau’s universal free-of-charge program for system similarity and geographical closeness. Hong Kong also noted Japan’s withdrawal of a national immunization program due to side effects reported in mass media. In the media reports, the head of Nationwide Cervical Cancer Victim Liaison Committee claimed compensation from the government for her daughter’s suspected complex regional pain syndrome and loss of walking ability caused by HPV vaccine injection; this gained considerable public attention in Japan [25].

Actors

We present stakeholders’ roles, interests, knowledge levels, self-reports of power (adjusted), and their positions in Table 1. We map the estimated power of each stakeholder based on the position of each—to indicate their potential influence (Fig. 2, Force-field mapping) [26]. We did not identify any opponents such as religious or anti-vaccine groups in document review or interviews of stakeholders. The highest level of influence over policy formation came from administrative authorities in health care system despite their ‘policy neutrality’; that is, they neither supported nor opposed the proposed universal program. Most stakeholders operated from within government institutions except for private family doctors. Although some of the doctors had connections with health departments because they provided technical assistance as consultants, their involvement was more limited as they operated only as individuals without institutional leverage. Private family doctors, teachers, and mothers had low levels of power level because they were not organized to exert influence collectively. Despite their limited impact on policy formation, they were a dominant source of engagement in implementation. We identified no coalition during the interviews.

Table 1 Analysis of Hong Kong stakeholders’ role, interest, knowledge level, power, and positionFig. 2

Hong Kong stakeholders in force-field mapping. Stakeholders at same level of position and power appear as a group. CHC community health center, NGO non-governmental organization, FPA family planning association

The two pharmaceutical companies reported to have played a limited role even though they possessed financial and other resources. Medical professionals had to divulge potential conflicts of interest to their colleagues and the public if their relationships and behavior might increase vaccine sales. Stakeholders reported that doctors’ influence could have been weakened if they were known to advise the pharmaceutical companies selling the HPV vaccine. Stakeholders told us that non-profit health organizations and academics held cautious views about cooperation with the industry on research related to HPV vaccination. Several stakeholders denied the industry’s invitation to conduct research together, saying they had avoided potential negative impact on the credibility and objectivity of the research to maximize public benefit. Accordingly, the pharmaceutical representatives reported their limited scope for industry involvement through these interactions with non-profits and academics.

Themes in policy processTheme 1: Perceptions about cervical cancer as a priority

Most stakeholders perceived cervical cancer prevention to be a high priority despite it not placing as a top health concern among women. The respondents used objective measures for justification of priority, including rank in cause of death, incidence rate, and number of cases diagnosed. A gynecologist reported that static incidence made cervical cancer no longer ‘eye-catching’ due to increasing incidence of other cancers in Hong Kong’s aging population. Some of the stakeholders also used comparisons with other developed countries’ incidence rates to determine priority of cervical cancer. These credible indicators provided a basis for the participant stakeholders to provide the assessments of their own position and level of power. The most often highlighted feature of cervical cancer was its susceptibility to prevention using the existing government-subsidized screening program. Interviewees without medical background tended to relate cervical cancer prevention to fertility and suggested that eligible women would prioritize cervical cancer prevention through regular screening.

Theme 2: Perceptions about voluntary HPV vaccination

Participants expressed mixed perceptions about voluntary HPV vaccination. An example of a positive opinion reported is “an active introduction with increasing awareness”; a negative one is “a complete failure” because the uptake rate in 10 years’ time of availability remained low. Most commented that family doctors did not contribute much to the success of this voluntary program by connecting patients with community health centers due to their low level of public health awareness about cervical cancer prevention. Interviewed mothers stated that mostly government action influenced their behaviors. Participants in the study cited absence of a visible strategy to promote HPV vaccination to have created a lack of confidence in the program, and confusion about what was expected of them.

Theme 3: Economic evaluation evidence

Several stakeholders emphasized the importance of economic evaluation as did all those who responded in writing from the health departments. Modeling estimates of the incremental cost-effectiveness ratio appear to be substantially below the criteria of per capita gross domestic product, thus justifying the vaccination of 12-year-old girls as a high value-for-money intervention [27]. However, stakeholders who valued the economic evaluation evidence varied in their assumptions, interpretations, and conclusions because they also differ in how they understood cost-effectiveness, based on comparing money invested and money saved from averted cancer cases. The stakeholders considered vaccine price to be the most controversial part; cost was the major driver for determining the ratio, but it was not fixed in a tiered pricing system when developed countries achieved low tender prices. The research team at the University of Hong Kong that completed the cost-effectiveness analysis in 2012 later conducted a cost benefit analysis and disseminated it at an academic conference of the Hong Kong Academy of Medicine in June 2017 [28].

Theme 4: The political action of pilot scheme

The Chief Executive Leung Chun-ying proposed a pilot scheme of providing free cervical cancer vaccination to eligible low-income girls in the Policy Address of 2016 before we started the interviews. The Community Care Fund under the Commission on Poverty launched this scheme and commissioned the Hong Kong Family Planning Association to provide free vaccination services to girls aged 9 to 18 who received Comprehensive Social Security Assistance, and to female students aged 9 or above who received full grants under the School Textbook Assistance Scheme [29]. The Scientific Committee on Vaccine Preventable Diseases posted a consensus statement on the use of HPV vaccine to prevent of cervical cancer on the government website in September of 2016, just before the start of the pilot scheme [30]. The CEO of Hong Kong Family Planning Association saw mounting of a program as a first organized course of action before a probable wide-scale program. Several stakeholders expressed concern from an epidemiological perspective about limited effectiveness of the pilot scheme at population level if no herd immunity was achieved. Also they found little evidence that the targeted girls were at high risk for HPV infection. Thus, they raised concerns about potential stigmatization of girls—based on an assumption that they were likely to be sexually active, or “labeling these underprivileged girls” given the conservative attitude about sexual activity among local population.

Interviewee 1 (Table 1) saw the pilot scheme as a politically motivated policy “on the radar screen” and commented that initiation of such a pilot scheme was reasonable from the public health viewpoint and that use of available funding from the Community Care Fund could make approval by the Legislative Council easy and quick. Another stakeholder commented that it seemed odd to make incremental changes in an immunization program, piloting in particular population or in particular places because she thought immunization program should cover adolescent girls in general.

Theme 5: Advocacy efforts to promote universal coverage for target girls

Several efforts to promote HPV vaccination have taken place. The vaccine industry, led by a private gynecologist, launched a first alliance early, when the private sector played an important role in the first several years between 2008 and 2012. Then two NGOs organized immunization service provision in local schools. One of the NGOs reported their efforts to communicate results with government health departments upon completion of their final report. Members of a committee of the Hong Kong College of Obstetrics & Gynecology also wrote a letter to the health departments, the only action taken by professional bodies. The government replied to this group, but these stakeholders had seen no government action by the date of our interview in 2016.

The largest party in Legislative Council paid some attention to HPV vaccination. Its Women’s Affairs Committee, in late 2013, expressed concern about provision of free HPV vaccines first to “under-privileged” girls before extending free vaccine to all adolescent girls. Early in 2014, the Women’s Affairs Committee organized a press briefing to catch attention of the Chief Executive of Hong Kong before the release of that year’s policy address [31, 32]. Mass media played a pivotal role in shaping issues for public debate. Andrew Work argued in a commentary that the “political risk” for the Hong Kong government for not having a cost-effective school-based program would be to show that the government had not cared to protect women, and thus it was not aligning Hong Kong with modern nations for HPV vaccination [33]. A local newspaper, the South China Morning Post, later published two reports around the time of the launch of the pilot scheme urging the Hong Kong government to provide a public program for all girls [34, 35]. A more recent report presented on state-run Radio Television HK in April 2017 recorded establishment of HPV Prevention Alliance by medical professionals to raise awareness of the public [36].

Policy content

Respondents viewed health education campaigns to be the most critical action for increasing awareness among the general population to bolster initiation of a universal program. Respondents also reported as important the extension of the ‘Pilot Scheme’ to cover more of the targeted girls along with professional training sessions to disseminate the latest evidence.

Despite of concerns about increasing workload and coordination with the education department and schools, stakeholders preferred school-based service delivery to achieve high parent acceptance and uptake rates. Respondents reported that Department of Health needed more evidence for co-administration of HPV with a booster dose of diphtheria and tetanus toxoids, acellular pertussis, and inactivated poliovirus vaccine for 12-year-old girls in schools. We found a lack of consensus on the best age at which to immunize, but respondents said that health education tailored for adolescents was essential to gain their assent.