Human papillomavirus immunisation of adolescent girls: improving coverage through multisectoral collaboration in MalaysiaBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4602 (Published 07 December 2018) Cite this as: BMJ 2018;363:k4602
- Saidatul N Buang, public health physician1,
- Safurah Ja’afar, associate professor2,
- Indra Pathmanathan, retired senior public health specialist3,
- Victoria Saint, independent consultant4
- 1Family Health Development Division, Ministry of Health, Kuala Lumpur, Malaysia
- 2Department of Community Medicine, International Medical University, Kuala Lumpur, Malaysia
- 3World Bank, Washington, DC, USA
- 4Berlin, Germany
- Correspondence to: S N Buang
Cervical cancer is the fourth most common cancer in women globally.1 Human papillomavirus (HPV) types 16 and 18 collectively cause 70% of cervical cancers and precancerous cervical lesions.1 The UN joint global programme on cervical cancer prevention and control includes HPV immunisation for girls as one of its three priorities at country level, together with screening and treatment for cervical pre-cancer, and diagnosis and treatment of invasive cervical cancer.2 In Malaysia, the age standardised cervical cancer rate is 7.8 per 100 000 females, making it the third most common cancer in women, with 4352 new cases reported for 2007-11.3 Malaysia’s HPV immunisation programme was introduced in 2010, within a healthcare system that has a credible track record (box 1, table 1). We present a case study of this programme and explore the role of multisectoral collaboration in achieving near universal immunisation of an estimated annual cohort of 250 000 13 year old girls.
Key facts about Malaysia
Population: 32 million, consisting of 7.7 million people 0-14 years, 22.3 million 15-64 years, and 2 million 65 years and above
Life expectancy: males 72.7 years; females 77.6 years
Infant mortality: 6.2 deaths under 1 year per 1000 live births
Urban population: Estimated as 75% in 20175
Poverty: 1.7% of population below the poverty line (2012)6
Malaysia’s nationwide healthcare system has a government led and heavily subsidised comprehensive public sector the cost of which is almost entirely borne by budget allocations, and a fee for service private sector that has grown considerably in the last 25 years
Primary healthcare coverage is provided through the large rural and semiurban health service that is connected to public sector hospitals in each state and the capital city through a referral system. In parallel, a large network of mainly urban private sector clinics provides mainly curative primary level care, and a rapidly increasing number of private hospitals provide secondary and tertiary care
Malaysia’s education system consists of pre-primary (4-5 years), primary (6-11), secondary (12-17), and tertiary (18-22) levels. Primary education is compulsory and largely universal for girls and boys (98.6% net enrolment rate); net enrolment rate for secondary education for females and males is 77.96% and 72.11%, respectively
The literacy rate for 15-24 year olds (2001) is about 98%
Case study: aims and methods
Malaysia’s HPV immunisation programme was selected from responses to a global call for proposals on multisectoral collaboration issued by the Partnership for Maternal, Newborn and Child Health (PMNCH).11 We aim to identify key factors in the successful collaboration, particularly during policy formulation, planning, and initial implementation, and report lessons learnt. A methods guide developed by PMNCH12 and methods specific to the case study were used to develop and evaluate this case (see supplementary material on bmj.com); these included reviewing available data, interviewing key informants, producing a working paper, and holding a stakeholder workshop to review the working paper and gather additional data and input.
Development of the national programme on HPV immunisation
Before the development of an effective HPV vaccine, cervical cancer prevention relied on early detection through cervical smear testing. Malaysia’s cervical cancer screening programme had consistently failed to achieve its target of three yearly screening of 40% of women aged 20-65. Poor performance of the screening programme caused considerable frustration within the Ministry of Health.13 The problems with the programme included its opportunistic rather than targeted nature, inadequate cytology services, insufficient funds, and negative perceptions and attitudes.1415
After the HPV vaccine was recognised as effective in preventing oncogenic genotypes of HPV,16 it was approved for use in Malaysia in 2007. The Ministry of Health recognised that the vaccine would be a useful addition to its cervical cancer prevention approach. High vaccine prices, however, initially prevented its inclusion in the national childhood immunisation programme, which is provided free of charge and had high coverage. Several initiatives that engaged the problem, policy, and political streams (table 2), as described in the model by Kingdon (2001),21 resulted in the government approving limited funding for a proposed HPV immunisation programme in 2009.22 As the HPV vaccines available at the time were expected to provide protection against only 70% of cervical cancer, cervical smear testing for women aged 20-65 was also continued and enhanced.
The objectives and design of the HPV immunisation programme reflected local strengths and constraints. The objective was the eventual reduction in the burden of cancer, and this was to be achieved by vaccinating girls through the existing school health programme. Girls were chosen as the target group because the programme aimed to reduce cervical cancer. This avoided the additional cost and human resources that would have arisen if boys had been included for the prevention of genital warts, as was the practice in some countries. A school based approach was chosen because the ongoing nationwide school health programme managed by the Ministry of Health was already providing measles/rubella and diphtheria/tetanus toxoid vaccination in 99% of schools in the country and achieving high coverage rates.23 The target age group for HPV immunisation was 13 year old girls. This group was chosen because more than 80% of this age group are enrolled in school and do not receive other vaccinations.24 The national HPV immunisation programme aimed to progressively build herd immunity in young adults. Successive cohorts of immunised seroconverted 13 year old girls would be protected when they became sexually active. Fig 1 outlines the programme timeline.
Initial government funds were only enough to purchase the vaccine and run promotional activities (table 3). The Ministry of Health faced the challenge of designing an effective programme to vaccinate about 250 000 girls annually, with no funding for additional staff, cold chains, or additional consumables.
Parental consent for daughters to receive the HPV vaccination has been more than 95% from year one of the programme.25 Of those for whom parental consent was given, completion of three doses has been more than 98%. Population coverage has been more than 80% throughout (fig 2) despite a decline of four percentage points after a policy change in 2013 that restricted free immunisation to public sector schools. Vaccine wastage has remained low (eg, 80 of 70 000 doses in 2010), as have adverse events following immunisation, which have ranged from 0.06% to 0.45%.26
Sustainability of HPV immunisation
From 2012, free HPV immunisation was fully integrated into the school health programme and is a key component of the national childhood immunisation programme. Financing for vaccine purchase is provided through the regular budgetary allocation, and staff schedules, logistics and cold chain maintenance, and performance monitoring have been integrated into respective programmes at district and state levels. For the older female population, screening continues with smear tests. In 2017, the initial cohort of immunised 13 year old girls reached age 20, and therefore the age for smear test screening was raised to 30-65 years (previously 20-65 years). The annual target of 40% of the eligible female population continues based on existing available financial and human resources. At the same time, different diagnostic methods are being explored (for example, conventional smear cytology, liquid base preparation, and testing HPV DNA), and cost effectiveness studies are being conducted by a local university.
Collaboration for programme implementation
We identified two themes that underpinned the success of the collaboration.
Collaborative work in planning and monitoring
Collaborative interagency work in planning and monitoring enabled the best use of resources. National roll out of the HPV immunisation programme required detailed, evidence based planning. Planning was both informed and supported by collaboration so that the two processes became mutually reinforcing. For example, almost 650 school health teams worked across about 2960 schools to vaccinate about 250 000 13 year old girls each year. Each girl had to be vaccinated with two or three doses at intervals of one and six months, without interrupting important curricular activities. The three dose schedule had to be completed within the school calendar year in order to minimise drop outs. HPV immunisation was an added task for the school health teams, who already carried out regular developmental assessments and screening, booster vaccinations, and health education. Additional nurses from other outreach programmes were used from time to time. Prior informed parental consent was needed for each girl, and logistical planning based on local data from schools and health teams was needed.
The long established interagency collaborative network of joint school health committees was activated. These committees (fig 3) provided the platform for collaboration between health and education sectors through overlapping subgroups.27 The introduction of the HPV immunisation programme energised the network of committees. Vertical collaborations between national, state, district, and local levels of the ministries of health and education supported information flow and accountability. At the same time horizontal linkages between the two sectors at each level supported information exchange and strengthened trust. Collaboration efforts contributed to overcoming some of the challenges of implementing the immunisation programme, including ensuring the best use of nurses in school health teams (table 4).
Senior managers in the health and education ministries established accountability by calling for regular progress reports. The collaborative mechanism was strengthened when the education sector was appointed to chair the joint school health committees to ensure appropriate participation and follow up in a programme that otherwise risked being viewed as “belonging” to the health sector.
Monitoring of HPV immunisation was integrated into the monitoring system of the ongoing school health programme, which was enhanced during the introductory two year period (2010-11). Operation rooms at national, state, and district level—previously only used for communicable diseases and emergencies—became the centre for the HPV immunisation programme. Detailed planning and monitoring strengthened collaboration, and integrated reporting and validation of data contributed to the programme’s accountability (table 4).
For example, additional refrigerators for vaccines closer to schools were needed, to store the large number of single dose vials and reduce travel time for school health teams. Sufficient vaccine for each school team had to be distributed from the national stock according to local schedules and stored at 640 delivery points across the country. To respond to this challenge, a parallel collaborative partnership developed between the Ministry of Health and the pharmaceutical company. When the Ministry of Health explained its difficulties in transporting and storing vaccines, the pharmaceutical company provided, at its own cost (about £200 000; $310 500), additional refrigerators and materials needed for injections because these could not be covered by the Ministry of Health budget (table 3). In addition, to ensure timely vaccine availability during the initial two year period, the pharmaceutical company provided delivery logistics and computer software to monitor cold chain integrity. Thus, the relations between the Ministry of Health and the pharmaceutical company evolved from a contractual agreement governed by procurement rules to an active collaborative partnership (box 2).
Perceptions of key stakeholders
“The relationship between the Ministries of Health and Education was symbiotic. We have collaborated previously and appreciated that MoH programmes brought great benefit to our girls. The HPV programme was unique in the number of schools and children involved and the intensity of the programme. It was a challenge but we are proud to have helped to deliver it successfully.”
former director general of education, Malaysia
“My experience working with the MoH on the HPV programme was rewarding. The MoH openly shared information on the constraints they faced and we were able to share our strengths to address these constraints. We were true partners in this meaningful venture and not mere suppliers of a commodity.”
former manager, vaccines division, multinational pharmaceutical companyRETURN TO TEXT
Collaborative work in communication
Collaboration supported effective communication strategies. Introducing a new vaccine for adolescent girls, particularly for a sexually transmitted infection in a socially conservative society, presented challenges. However, the multisectoral collaboration devised communication and surveillance strategies to overcome these problems.
Rare but serious adverse reactions, occurring locally or in other countries, could have attracted negative publicity and resulted in a drastic decrease in immunisation coverage in Malaysia, potentially putting the success of the childhood immunisation programme at risk. A small local school survey by the Ministry of Health communications team used focus group discussions to assess student perceptions. This indicated widespread confusion between HIV and HPV, as well as concerns that the vaccine would promote sexual promiscuity, have serious unanticipated side effects, and contravene Islamic law.
In response, the Ministry of Health designed a two pronged, partnership oriented communication strategy that enhanced collaboration with both the education sector and the mass media. Training and support packages were implemented for frontline staff, such as teachers and school health teams, who were known to be key influencers of the perspectives and behaviour of students and parents.28 Mass media in four languages (Bahasa Malaysia, English, Chinese and Tamil) were used to inform and motivate the general public, especially parents (figs 4 and 5). The key message was “HPV immunisation given when your daughters are young will protect them when they eventually get married”. This message avoided association between vaccine protection and early sexual activity.
Malaysia has a large and diverse mass media, which includes traditional media such as television, radio, and print, and also social media.29 The Ministry of Health worked with the media to mobilise public opinion in favour of immunisation, empower parents to consent to immunisation for their daughters, and provide appropriate and timely information to address individual concerns. The collaboration was based on a contractual agreement and strong interpersonal relationships. Using its positive image as an agency devoted to public welfare, the Ministry of Health obtained prime time radio and television slots at reduced rates. Together with a larger than usual health promotion budget this enabled wide media exposure, which helped gain support for and acceptance of HPV immunisation. At the same time, the Ministry of Health used Facebook, Twitter, and a dedicated telephone hotline to provide a direct channel for parents and the general public to raise concerns and receive immediate responses from informed and credible professionals.
The Ministry of Health also provided evidence to the national Islamic religious authority (JAKIM) that the vaccine met Islamic requirements. As a result, this authority issued a fatwa that the vaccine was permitted for use in the interest of protecting women against cervical cancer.30 The fatwa was used widely in briefings for teachers, parents, and schoolchildren and in road shows—information briefings and meetings for members of the public. Other activities included monitoring rumours about HPV vaccination and responding promptly to them, and monitoring adverse effects following immunisation (table 5).
Characteristics of collaborations that contributed to success
Malaysia’s health sector has long benefited from a culture and environment that support intra-agency, interagency, and multisectoral collaboration (box 3). Building on this tradition, Malaysia’s Ministry of Health supported and improved a number of relationships between stakeholders to develop and implement solutions to overcome a lack of resources and operational capacity to implement the HPV immunisation programme.
Context of multisectoral collaboration for health in Malaysia
“Our recipe for success? Create an ecosystem that facilitates the engagement of partners and the community. …. We have an organizational culture that promotes solutions through innovative technology and partnerships.”
Director General of Health, Dato Seri Noor Hisham Abdullah
The ministries of health and education have a long history of close collaboration including joint and consultative policy development and implementation of programmes (eg, for school health and dental care, and for the national school curriculum’s coverage of health topics). Collaboration mechanisms (eg, standing committees) and strong institutional memory exist at national, state, and local levels
Examples of well established collaboration between the Ministry of Health and other sectors include the village development committee partnership between health staff and rural village heads (Ketua Kampung) working for sanitation and disease control, advisory panels for the network of public sector primary care clinics and hospitals providing an official communication channel between the healthcare sector and the community, and the Ministry of Health’s ongoing relationships with the media and religious authorities
More recently the national government has adopted the national blue ocean strategy which aims to foster collaboration between ministries, agencies, levels of government, and the private sector to break down silos in order to achieve faster implementation and better outcomes at a lower cost31
Programme stakeholders fall into three categories: key players, close supporters, and influencers (fig 6). The relationships between these stakeholders were of different degrees of integration,32: cooperation (sharing of information and mutual support), coordination (having compatible goals and common tasks), and collaboration (having integrated strategies and a collective purpose, table 6).
Long standing public sector collaboration, even when governed by well established policies and operational mechanisms, needed to be supported and kept effective and dynamic. Stakeholders also needed to be mobilised specifically for the HPV vaccination programme (tables 4 and 6). A key success factor in the collaborations was the reshaping of relationships, away from supervisor-subordinate, manager-helper, or manager-client to true partnership (box 4). An important condition for this was the three layers of strong leadership within the Ministry of Health. Top management provided political commitment and direction and demanded accountability, middle management, which had political, policy, and programmatic skills, guided the detailed planning and ensured all stakeholders were listened to and heard, and technical management was innovative and responsive. Communication and listening were essential to foster trust. An example of this is the joint school health committees, which were energised by a new programme in which roles were clearly defined and acceptable to each stakeholder, and which respected the primary mandates of the stakeholders.
Factors contributing to successful collaboration in Malaysia’s programme on HPV immunisation
Factors supporting effective multisectoral collaboration included the following.
Between the health and education sectors
Mutual trust and respect were built through timely exchange of specific information, such as training packages, the key message, informed consent from parents, and monitoring adverse events following immunisation
Between the health sector and news media
Transparent, credible, and timely communication was maintained on issues such as Islamic halal requirements and adverse events following immunisation
Between the health sector and parents and schoolchildren
Engagement rather than advocacy was used; parents were treated as partners in the programme and had convenient and simple access to authorities to discuss and resolve concerns
Collaboration alone, however, was not sufficient. Other important and mutually reinforcing elements included:
Evidence based planning and implementation
Building trust and credibility
Strategic communication and innovative use of mass media
These relationships developed within a supportive organisational culture that had built up and grown over time. The Ministry of Health has a strong partnership culture within the ministry and between it and other related government agencies such as those for education, rural development, women, and family development. The value systems and priorities that have governed health system development in the country include “prevention is better than cure”, community participation, safety and quality, creative innovations (including to reduce costs), accountability, and sustainability. The HPV immunisation programme illustrates values more recently adopted by Malaysia’s Ministry of Health—namely, “patient before patent” and an engagement rather than an authority approach to partnership.
Importantly, collaboration is only one of several factors that contributed to the programme’s success. The HPV immunisation programme is backed by substantial scientific evidence, has clear benefits for cancer prevention, and is relatively simple to administer at the point of delivery. In contrast, thalassaemia screening in Malaysia’s schools, offered by the Ministry of Health through similar collaborative networks, has not achieved comparable coverage levels. This may be because thalassaemia screening is complex to execute and requires long term follow up of carriers, data demonstrating effectiveness are lacking, and its benefit is not clear to potential recipients.
Nevertheless, longer lasting benefits may have emerged from the collaborations established during the different phases of Malaysia’s HPV programme. These have their roots in the specific underlying principles of the collaborations, including providing forums to facilitate formal communication and agreements, familiarity and trust, and strengthened stakeholder satisfaction and empowerment. For example, coordination with the pharmaceutical companies led to cost savings through reduced vaccine price, strengthening of the cold chain, and delivery to the point of use. The Ministry of Health has recognised the potential for future innovation through new or renewed partnerships between agencies (government as well as private, such as medical associations)—for example, to establish centralised pharmaceutical procurement in order to negotiate cost savings with suppliers. The Ministry of Health has presented its experience of the HPV programme in many regional and global conferences since 2010. Staff of the programme also provided inputs to a 2017 WHO publication on HPV vaccine communication,33 and engaged in a study tour in 2011 with staff of the Ministry of Health of Brunei to share their experiences.
Although the HPV programme aimed to vaccinate all 13 year old girls in the country, an estimated 15% were not vaccinated. Of these, most were not enrolled in school, while 1-2% were attending school but their parents did not give consent for immunisation. We have few data about the girls not attending school. Studies suggest they are probably from lower socioeconomic groups, particularly those living in remote areas where healthcare access is difficult and provided through periodic visits by mobile health teams.34 Furthermore, the value of providing HPV immunisation in boys is increasingly recognised—for example, for benign and malignant anogenital disease, as well as head and neck lesions.35 Closing this gap in coverage is a challenge, and collaboration between sectors may again prove valuable in efforts to reach these groups.
Programme performance is monitored by coverage rates aggregated at the district level. Therefore, variation in uptake and coverage by geographical area, school type, or other relevant factors is not possible at this time. In addition, Malaysia cannot yet afford to monitor seroconversion rates; however, Australia’s experience suggests that seroconversion rates in Malaysia could be high.36
In the first years of the programme, the Ministry of Health received through the hotline and Facebook questions about and demands for free immunisation for teenage girls at or over 13 years. Those aged 13 were offered free immunisation in health centres, while older girls were initially referred to the private sector In a parallel initiative in 2012, the ministry of women and child development offered free HPV immunisation to 18 year old girls, financed through a government budget allocation separate from that of the Ministry of Health. It was first available in clinics of the ministry of women and child development which were mainly in urban areas, and then offered for free to females enrolled in universities through collaboration with the ministry of higher education. However, the uptake was low. The collaboration between the Ministry of Health and the ministry of women and child development was mostly about provision of technical advice, information, and educational materials, rather than design, planning, implementation, or monitoring. The data on the programme achievements are not robust enough to be used for evaluation. This initiative ended when the first cohort of 13 year olds from school reached 18 years.
In 2013, government policy changed so that children enrolled in private schools were no longer entitled to free immunisation. The rationale was that these children belonged to higher income households and could afford vaccination in private, fee-for-service medical clinics. A slight decline in coverage followed (fig 2), but it is unclear whether this was due to the lack of a clear reporting mechanism from the private sector or to lower coverage.
In this case study, multisectoral collaboration was used to overcome a lack of resources by generating additional resources and making the best use of the resources available. It supported improvement and innovation in, for example, vaccine delivery and cold chain integrity, surveillance, and strategic communications. As a result of the collaboration, the implementation of the HPV programme was strengthened and was detailed, evidence based, and on time, which contributed to the success of Malaysia’s HPV immunisation programme.
Malaysia launched a national programme on HPV immunisation in 2010 and within two years achieved its target of vaccinating about 250 000 13 year old school girls each year
The Ministry of Health collaborated with a range of stakeholders and built strong partnerships based on mutual trust, supported by policies and institutional structures, as well as ad hoc collaborations based on circumstances and personal relationships
Collaboration within the programme brought benefits, such as mobilisation and best use of resources, and opportunities for innovative problem solving
Collaboration contributed to detailed implementation planning of the programme to anticipate needs and problems, and was underpinned by strong leadership that supported listening to all and accountability
See www.bmj.com/multisectoral-collaboration for other articles in the series.
Contributors and sources:This article draws on a longer case study report for the PMNCH, drafted by SNB, SJ, and IP, and with inputs by VS, based on Ministry of Health documents and verbal inputs from senior and midlevel managers in the ministries of health and education, pharmaceutical companies, and parents. All authors contributed to the drafting of the manuscript. IP and VS integrated feedback and produced subsequent drafts. All authors meet the ICMJE criteria for authorship and have read and approved the manuscript. SNB is the guarantor.
Competing interests: All authors have read and understood the BMJ policy on declaration of interests and declare the following interests: funding from PMNCH as part of the Success Factors case study series, including funding to SJ, IP and VS for consultancy. The views expressed are those of the authors and do not necessarily reflect those of PMNCH or WHO.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a series proposed by the Partnership for Maternal Newborn and Child Health (PMNCH) hosted by the World Health Organization and commissioned by The BMJ, which peer reviewed, edited, and made the decision to publish the article. Open access fees for the series are funded by the PMNCH.
This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (https://creativecommons.org/licenses/by-nc/3.0/igo/), which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.