China s Seasonal Influenza Vaccination Policy in a Post-Health Care Reform Era

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1 bs_bs_banner Asia & the Pacific Policy Studies, vol. 2, no. 2, pp doi: /app5.86 Special Research Article on Health Policy China s Seasonal Influenza Vaccination Policy in a Post-Health Care Reform Era Ningzhen Ruan, Thao Nguyen and Kellynn Khor* Abstract Vaccination is recognised as one of the most effective ways to combat seasonal influenza a disease that exerts significant social and economic costs, yet is often neglected by policymakers and the vaccine target population in developing countries. The situation in China is no exception with seasonal influenza vaccine remaining as a class II vaccine and being financed by citizens out-of-pocket payments. The different cultural backgrounds, climate patterns and living standards across China further complicate the policymaking process of developing national level policy guidelines. Nevertheless, China s recent health care reform that focuses on preventive care, elderly care and equitable health care access has motivated policy-makers at the local level to formulate policies facilitating seasonal influenza vaccination provision. This article seeks to understand this process at the city level under China s current economic transition background, and aims to identify policy experiences that may be applicable for the larger Asia-Pacific region. Key words: China, public health policy, health care reform, seasonal influenza, vaccination * Lee Kuan Yew School of Public Policy, 469C Bukit Timah Road, Singapore Corresponding author: Ruan, ningzhen@u.nus.edu. 1. Underprioritisation of Seasonal Influenza Vaccination Policies in China Influenza is an acute and highly contagious viral infection that affects people across all age groups. It has the potential to cause serious health problems and even lead to death for certain high-risk groups. Despite of its severe impacts on health, seasonal influenza is also one of the best-known preventable diseases its social and economic costs are avoidable through improved accessibility of vaccination. Prevention through seasonal influenza vaccination has proven to be cost-effective relative to providing either treatment or supportive care alone. In most developed countries, influenza vaccines are provided free-of-charge to high-risk groups in target areas. China, with the world s largest population and diverse climate patterns, is highly vulnerable to the disease. Yet seasonal influenza vaccine remains a class II vaccine outside China s National Immunization Program (NIP). It is purchased by consumers voluntarily through out-of-pocket payment. The low prioritisation of seasonal influenza vaccination is worrying due to three main reasons. First, seasonal influenza imposes a high disease burden in China as measured by mortality rates. China has two influenza seasons the winter seasonal peak in temperate North China and the year-round circulation in tropical and subtropical South China. The annual influenzaassociated excess mortality is 18.0 (range: ) and 11.3 (range: ) deaths per 100,000 people in northern and southern Chinese cities respectively (Feng et al. 2012).. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

2 Ruan et al.: China s Seasonal Influenza Vaccine Policy 215 Second, hospitalisation from influenza infections also creates considerable economic burden on the patients and their families. Research on direct medical cost of influenza in three hospitals in Sichuan, Hunan and Shandong Provinces found the direct medical cost for influenza-related hospitalisation to range between US$80 and US$27,545 in 2010 (Zhou et al. 2013). The social and financial burden can also be seen, although difficult to be measured, in terms of lost days of work and school, and losses in productivity and growth. Third, China s influenza vaccine production capacity could be undermined by the low prioritisation of the vaccination programs. China s total production capacity from the domestic suppliers in 2009 was estimated to be million doses, while the estimated target size of the at-risk population for seasonal influenza is million, or 43 per cent of China s population (Feng et al. 2010). Without sufficient policy focus and market demand, manufacturers are reluctant to further increase their existing capacity. The insufficient production capacity can undermine China s preparedness in situations of influenza epidemics. 2. Research Focus and Methodology Without a national provision program, only about 2 per cent of the population in China are protected by vaccination against seasonal influenza (China National Biotec Group 2013, unpublished data). The highest vaccination rate is among children while a lower rate is observed among the elderly who are subjected to disproportionately higher influenza-related mortality. China s Law on Prevention and Treatment of Infectious Diseases allows subnational governments or health departments in China to add vaccines of emergency immunisation within their financial capability at their own discretion. A few more-developed city governments currently finance or subsidise seasonal influenza vaccines for high-risk groups as Table 1 indicates. To understand the vaccination policy drivers and process at the city levels, primary research fieldwork was conducted in three Chinese cities Beijing city in northern China that fully subsidises seasonal influenza vaccines to high-risk groups; Ningbo city in Yangtze delta that covers seasonal influenza vaccine with social health insurance; and Guangzhou city in southern China that has no available seasonal influenza vaccination programs. Interviews were conducted with officials from various government agencies and frontline health care workers in the central and city levels to understand the perspectives of national and local policy-makers, and that of frontline workers at the community level. Interviews were also conducted with Chinese academics that have been engaging with the topic to reduce bias and to ensure validity of the findings. Secondary literature analysis was also undertaken to gain a more comprehensive understanding of China s health care system, including its vaccination policies, health care financing system, preventive care situation and its medical reform scheme. The existing literature reviewed included researches by government bodies, think tanks and independent bodies, as well as official press releases and documents. The literature review covered Table 1 Existing Seasonal Influenza Vaccine Programs in Sample Chinese Cities Cities Year Program Beijing 2007 onwards Free for elderly above 60 years old and school children Karamay 2008 onwards Free for elderly above 60 years old, and children of 3 7 years old Shanghai Free for high-risk individuals: elderly above 60 years old, students, and health workers in the season for World Expo 2010 Xi an 2004 onwards Allowing payment for vaccines using Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) Ningbo 2012 onwards Allowing payment for vaccines using UEBMI and URBMI Zhuhai 2013 onwards Allowing payment for vaccines using UEBMI and URBMI

3 216 Asia & the Pacific Policy Studies May 2015 documents focusing within and outside China in English and Mandarin to provide both global context and local understanding of the challenges and opportunities encountered by Chinese cities in addressing the policy issue. 3. Seasonal Influenza Vaccination Policy Challenges 3.1 Lack of Consumer Demand Consumer demand for seasonal influenza vaccine in many parts of China remained significantly lower than the 75 per cent World Health Organization (WHO) recommended rate. Studies found seasonal influenza vaccination rates among elderly survey participants above 60 years old to be 18.6 per cent in Shenzhen city in 2002, 11.1 per cent in Tianjin city in 2005 (Wang et al. 2006) and 5.39 per cent in Hangzhou city in 2011 (Zhang et al. 2011). The highest rate was observed in Beijing (52.9 per cent in 2011), which fully subsidises seasonal influenza vaccine to highrisk groups (Dong et al. 2005; Ning et al. 2012). The cost of vaccination, the inadequate access and the lack of awareness all directly affect customers demand for seasonal influenza vaccines. Cost of Vaccination The price of seasonal influenza vaccine for adults in China ranges between US$9 and 15 (RMB60 80), which is equal or above average daily wage in many regions (Feng et al. 2012). Many elderly are reluctant to go for seasonal influenza vaccination due to economic costs, as found by surveys done in both Tianjin and Beijing (Wang et al. 2006). Price factor does not affect the vaccination rate among children, reflecting disproportionate health care investment towards the young in Chinese societies. The cost of vaccination also affects the elderly in rural areas more than in urban cities, due to their different price elasticity of demand for class II vaccines. For example, before 2007, vaccination rates among the elderly in rural and urban Beijing were comparable. Since Beijing city started providing free seasonal influenza vaccinations in 2007, immunisation rates among the rural elderly increased to more than 70 per cent consistently from 2007 to 2010, while rates among the urban elderly was only about 40 per cent (Wang et al. 2013). Inadequate Vaccine Access The relatively low take-up rate among elderly of a higher income category reflects the presence of non-monetary demand factors, such as the inadequacy of the existing immunisation delivery system, particularly for adults. Mass vaccination in schools or workplaces are discouraged or even prohibited in many cities. Citizens can only receive vaccination at designated point of vaccinations (POVs) in clinics or hospitals. The transportation cost, waiting time and time off work all present considerable costs that reduce consumers willingness and capacity to be vaccinated, or to accompany elderly or young family members to the POVs. Many elderly people with chronic diseases also have difficulty traveling. The lack of POVs near their neighbourhoods often reduces their chances of getting vaccinated. Lack of Awareness Many Chinese citizens are unsure of the differences between influenza and a common cold, partly due to influenza s Chinese name Liu Gan, which bears similarities to cold (Gan Mao). The mild symptoms of cold affect people s judgement of the risks of influenza. The lack of awareness of possible influenza complications leads many to perceive it as a minor illness that can be self-treated with overthe-counter medication. A further lack of understanding of vaccine mechanisms reduces consumers willingness to be vaccinated. Studies show that per cent of participants assume influenza vaccinations are effective against the common cold (Dong et al. 2005; Wang et al. 2006) and tend to perceive vaccine as ineffective if they get a cold post-vaccination. There is also a lack of awareness on the need of annual seasonal influenza vaccination due to its high virus mutation rate, even among health care workers. A survey has found that while doctors have a basic understanding of

4 Ruan et al.: China s Seasonal Influenza Vaccine Policy 217 vaccination, they too have inadequate understanding of flu virus mutation, leading them to question vaccine effectiveness (Buoyancy 2009, unpublished data). The lack of participation and inaccurate advice from health care workers can negatively influence public attitudes and knowledge towards influenza vaccines. Chinese consumers also hold concerns over vaccine safety. Patients generally accept possible side effects for curative medicines. Vaccines, however, are injected into presumed healthy persons the erroneous correlation of side effects with vaccine quality means attributing any illnesses in the post-vaccination period to the vaccines. Media publicity over isolated cases of adverse effects can further induce public fear. The current lack of trust in China s health care system also exacerbates this concern. 3.2 Unsustainable Program Financing Constrained Government Budget Policy programs may obtain each dose of seasonal influenza vaccine at the price of RMB30. 1 With the at-risk target population of million or 42 per cent of China s population (Feng et al. 2010), the financial budget required at the national level to include seasonal influenza vaccine as a class I vaccine will be RMB17.12 billion, equivalent to three times the current NIP total annual expenditure of RMB5 billion (Wen 2011). It is thus unlikely that the central government will provide seasonal influenza vaccine free of charge to all target population in the short term. Inflexible Risk Pool Resources All Chinese citizens are covered by one of the three social health insurance schemes: Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NCMS). The BMI schemes are administered by the Ministry of Human Resources and Social Security, while 1. This price is assumed as bulk-buying price, and is lower than the current market price of RMB60-80 per dose. The price is from Beijing Municipal Bureau of Health Invitation for Bids for 2013 Seasonal Influenza Vaccine (CCGP 2013). the NCMS is administered by the National Health and Family Planning Commission (NHFPC). The three social insurance schemes were designed to provide protection against curative expenses. Preventive services such as vaccination are seldom covered, even when balances in these insurance schemes are underutilised, such as the RMB764.4 billion UEBMI account balance reported for 2012 (Xinhua News Agency 2013, unpublished data). The inflexibility of utilising the financial resources in social health insurance for preventive care limits policy-makers capacity to formulate vaccine provision programs. Underutilisation of Alternative Resources There is also an underutilisation of alternative resources for financing seasonal influenza vaccines in China due to the fear of conflict of interests. The Chinese government has exerted more pressure on health care service providers and pharmaceutical companies in its recent effort to combat commercial corruptive practices. Government officials, experts and doctors are more cautious about collaborating with the private sector at the moment. Although more non-governmental organisations (NGOs) are devoting their resource to deliver health care service in China, the legal infrastructure and administrative institutions are not yet able to accommodate this development. The absence of established accountability mechanisms to monitor NGOs, charities and other civil society groups is restricting these civil society forces from participating more extensively in health care service provisions, especially as vaccines are biological products that require strict accountability measures. 3.3 Absence of Supporting Policy Environment Competing Priorities for Policy Commitments After a period of decentralisation, Chinese central government has reclaimed its dominance via tax and fiscal reforms. While the central government can exert great top-down pressure on local authorities, local leaders at the provincial level also enjoy great discretion

5 218 Asia & the Pacific Policy Studies May 2015 in policymaking as the central policies are usually formulated in broad terms to account for the vast regional differences in China. At the city level, the bureaucratic structure is complex with a muddle of vertical and horizontal reporting links. The complex matrix structure implies that any potential policy or program has to be the result of long deliberation between the different agencies and departments with varied interests. Within the health care system, there are competing priorities among different health policy agendas. In China s context, curative care still holds a higher policy priority than preventive care. Therapeutic medicine is seen as a better political investment as the results are more measurable in the short term. Even within preventive services, there are also competing agendas. Chronic diseases such as diabetes, cardiovascular diseases and mental illness; parasitic diseases; and communicable diseases such as HIV/AIDS all compete with influenza for policy importance and resources. Vaccines against rabies, rotavirus and human papilloma virus are also competing for future NIP inclusion. As a preventive care service, seasonal influenza vaccine s social benefit is long term and is relatively difficult to quantify without prior data collection. Local leaders, bounded by performance evaluation concerns, tend to prefer policies with more visible results in the short run. Without commitment from provincial or city level leaders, there is little motivation for policy-makers to implement any programs outside of their job requirements. In addition, the responsibilities of Center for Disease Control and Prevention (CDC) employees and health care workers at POVs are more specific in the NIP implementation. Class II vaccines are planned to be market driven. Frontline health care workers often would not actively promote class II vaccines to end-users because they would not want to be responsible for any potential accidents or disputes resultant of such vaccinations. Insufficient Scientific Evidence The inability to quantify local disease burden and the lack of sufficient high-quality economic analysis can also affect policymaking, especially for policy-makers that have limited knowledge of influenza disease and vaccine efficacies. There is extensive research on the effectiveness of seasonal influenza vaccines in developed countries. Chinese policy-makers, however, often require local evidence to make their decisions. Chinese researchers have conducted a few studies on the effectiveness of influenza vaccine among elderly or children. Though most local studies are positive on vaccine effectiveness on the elderly and children, their quality is inconsistent with varied sample sizes and differing postvaccination time intervals, giving rise to temporal problems. There are also limited continuous studies in any one location to account for vaccine effects consistency. The vast regional differences in climate, access to medical care, socioeconomic determinants of health and rural-urban variables are unaccounted for with very few high-quality cross-regional systematic studies. Interviewees from Guangdong particularly highlighted the importance and urgency of such studies as subtropical cities in Guangdong province have significantly different influenza patterns compared with Northern Chinese cities. China currently adopts only northern hemisphere formulation of seasonal influenza vaccines, which may not be able to provide full protection against the prevailing influenza strains affecting southern Chinese cities. Studies on the effectiveness of seasonal influenza vaccines in southern China if not designed carefully with consideration on the vaccine formulation difference between the two hemispheres may thus inaccurately influence policy-makers evaluation of seasonal influenza vaccine programs. Economic evaluations of vaccination programs tend to adopt narrow perspectives of evaluation criteria such as health care cost saving, number of clinic visits, hospitalisation days or transportation costs with few studies systematically accounting for all of these factors. Studies of influenza disease burden largely rely on excess mortality rate estimation from mathematical models, neglecting

6 Ruan et al.: China s Seasonal Influenza Vaccine Policy 219 important indirect costs such as community externality. 2 Interviews with experts also confirmed this limitation. Mobilising policymakers commitment requires more certainty in disease burden calculation and more robust economic evaluation. Adults and the elderly in China usually do not have immunisation records due to weak information and communications technology infrastructure. The lack of health care registry hinders studies on seasonal influenza vaccine effectiveness on patients with complications or chronic diseases. The low policy prioritisation limits the amount of grants channeled to influenza-related research. As a result, CDCs and POVs have little motivation to collect data and maintain records related to seasonal influenza vaccine. Absence of Key Advocators China has an Expert Advisory Committee on Immunization Program (EACIP) that advises the NHFPC on immunisation programs and strategies. The Committee provides evidencebased reviews to identify diseases to be prioritised for vaccination programs. There is yet to be strong advocacy for seasonal influenza vaccine from the EACIP or other medical associations. The WHO has published a recommendation on seasonal influenza vaccination among elderly citizens, providing important support for policy-makers to formulate seasonal influenza vaccine policies. International NGOs and donors can play important roles in advocating government agenda with their extensive experiences. The presence of these organisations is currently limited in China, especially in the domain of seasonal influenza vaccine. Media has the potential to be an influential policy advocator. Public perception and opinion can influence local leaders decisions. Media reports can also effectively affect the knowledge, attitude and practice of the general public. Different media outlets have the potential to be more active in promoting public 2. Such as community externality arising from influenza transmission, productivity loss, absenteeism, time cost of family members who take leave from work, and medical costs related to complications. health knowledge, and providing information about seasonal influenza. Currently in China, media coverage on seasonal influenza is only available during the disease peak seasons, which is after the optimal timing of vaccination. 4. China s Health Care Reform and Policy Opportunities There are a few existing city-level programs initiated by local governments to improve access to seasonal influenza vaccine. These are encouraging improvements and as pilot studies that allow for the analysis of policy opportunities in vaccine provision programs against China s health care reform background. 4.1 Health Care Reform in China China s previous profit-driven, fee-for-service health care system was heavily reliant on the sale of pharmaceuticals and out-of-pocket payments for hospital services. High medical costs, an inadequate health insurance system, and urban-rural disparities in health care access and financial security had slowed down improvements in life expectancy and caused major public dissatisfaction. The 2003 severe acute respiratory syndrome (SARS) outbreak highlighted the inadequacies of China s health care system. Responding to the shortcomings of the system, China s State Council announced an ambitious health care reform plan in April 2009 with the goal of provision of safe, effective and affordable basic health care for all by 2020 (Zhao & Huang 2010). The Chinese government has invested US$125 billion (RMB 850 billion) during the first phase of reform ( ), making remarkable achievements in providing equitable, accessible and affordable health care, with 95 per cent of the population covered by basic medical insurance (Information Office of the State Council 2012) and improved access to grassroots-level medical and health service facilities. The second and ongoing phase of the reform was marked with the 12th 5-Year Plan for

7 220 Asia & the Pacific Policy Studies May 2015 Health Sector Development ( ). Policy priorities in this phase include health care infrastructure, service networks, medical insurance systems and public hospital reform. Prevention and control systems for major diseases will be strengthened, with technology and health information systems receiving greater support (Western Pacific Region World Health Organization 2013). Further evaluation and adjustments will be made during the third phase ( ). If successfully implemented, this reform would address the many pressing concerns Chinese citizens have over the health care system. 4.2 City-Level Vaccine Provision and Policy Opportunities Refocusing of Policy Goals According to Yang (2011), the implementation of policies in China ultimately depends on the organizational and financial resources that China s leadership is willing to devote to, and the structure of incentives facing local authorities. The seasonal influenza programs in Beijing and other cities are widely agreed to be results of the high commitment from local governors towards public health and preventive care initiatives. The local government leader in charge of health sector, usually a mayor of the city, is the most important push factor in a typical city-level public health policy process in China, as illustrated in Figure 1. At the centre of the policy process is the Bureau of Health, under the guidance of the NHFPC, which evaluates evidence provided by experts and researchers, and develops initial proposals based on the evidence. The proposal is typically submitted to the local governor who would coordinate among the different agencies to initiate discussions and collect feedback if convinced by the value of the proposal. These agencies typically include the Bureau of Finance for budgets, the Bureau of Figure 1 City-Level Public Health Policy Process in China

8 Ruan et al.: China s Seasonal Influenza Vaccine Policy 221 Human Resources and Social Security for UEBMI and URBMI, Bureau of Civil Affairs for social safety net for the poor, Bureau of Education for awareness campaigns, Bureau of Food and Drug Administration for vaccine safety, and other related agencies. This process is often a negotiation between different departments to compete for city resources and to identify responsibilities. If a proposal is agreed upon, the local governor will review and approve it. The policy guidelines are then disseminated to technical and professional agencies such as the CDCs and other health service providers which will implement the policies. The monitoring, evaluation and review of policies may be conducted by CDCs and service provides, or by a thirdparty organisations to ensure objectivity and transparency. Although the policy process is mainly government led, the academic community, private sector, media and general public would be consulted to increase policy participation at all levels. The explicit health care reform policy goals of increasing average life expectancy can pressure local policy-makers to re-evaluate the prioritisation of preventive care. The health care needs of an ageing population also facilitated the recognition of immunisation s long-term benefits including the positive social externalities. The increased number of policy entrepreneurs with long-term visions championing the cause of preventive care can bring along the necessary coordination and resources from different bureaus and departments to achieve a committed implementation process that is important for projects that yield only visible results in the long term. Improving Vaccine Provision and Access Vaccines are biological products and require special logistics handling in a cold chain in the delivery process to maintain vaccine effectiveness. China CDC used to adopt a vertical centralised procurement system by province (Li et al. 2007). Interviews with CDC officials indicated that the system has been improved after the health care reform lower level CDCs can now directly order vaccines from manufacturers, and are no longer fully dependent on provincial CDCs for vaccine procurement. This process enhances the efficiency of procurement, and empowers lower level CDCs to select vaccines which suit their needs and resources better. The procurement process is generally open and competitive. As a part of the bidding process, CDCs evaluate potential suppliers and assign scores for different factors, including product quality, service and price. Manufacturers with the highest scores will be chosen to supply seasonal influenza vaccine to citizens. Pricing of vaccine is influenced by mark-up, but local governments in some cities may regulate for a final equal price for consumers. The health care reform aims to establish a comprehensive medical and health service system with increased accessibility, quality and efficiency to cover citizens in different regions. This policy agenda has facilitated the construction of community health centres (CHCs) that are located near residential neighbourhoods. CHCs that are close to home have enormous potential in hosting POVs that can increase the accessibility of adult immunisation, making it particularly convenient for elderly with limited mobility. Beijing city has innovatively provided doorto-door seasonal influenza vaccination projects based on requests of homebound elderly. Developing Evidence-Based Policies The renewed policy agenda allows policymakers to devote more resources on surveillance and data collection, epidemiology studies, economic efficacy studies, as well as policy researches. After combating a few influenza-related epidemics, China has established a comprehensive Influenza-Like Illness surveillance network made up of 411 network labs and 556 sentinel hospitals (Hongjie Y 2013, unpublished data). This influenza surveillance network has been recognised for its efficiency and transparency, with Beijing being one of five WHO collaborating centres worldwide for influenza surveillance and vaccine development. The authors field studies in Guangdong found all levels of CDCs mobilised to monitor

9 222 Asia & the Pacific Policy Studies May 2015 local influenza situation and regularly provide data updates to the central CDC. Professionals in the Guangdong CDC have also tested innovative surveillance methods such as Google Trends in Chinese language and online data to identify disease activity and detect signals of potential outbreaks (Kang et al. 2013). The surveillance system allows for the collection of more accurate data, contributing to disease epidemiology and economic epidemiology analysis. Private sector players including seasonal influenza vaccine manufacturers are also actively involved in the data collection and epidemiology research process. Where adult immunisation records are largely missing from the POVs data collection process, vaccine manufacturers sales information on adult dose could provide useful estimates. Multi-national vaccine manufacturers have often established vast amount of experiences and expertise in the epidemiology and cost-effectiveness studies of the disease. While noting on the potential commercial interests of the private sector players, local health care centres with limited research capacities can still leverage on the models and researches from these companies, and tailor the studies to their local contexts. With more high-quality local evidence, policy-makers will be empowered to make more effective policy decisions. Mobilising Alternative Resources With the health care reform goals of reducing out-of-pocket payments, the cost of seasonal influenza vaccination should be reduced for high-risk individuals, especially for elderly citizens above 60 years old. Provinces and cities in China maintain discretion to finance fully or subsidise partially vaccines outside the NIP list from their local revenues. For example, Beijing Municipal Bureau of Health had set a budget of RMB54 million for 1.2 million doses in 2013 (CCGP 2013), out of its RMB10.24 billion total health care expenditure for citizens above 60 years old and for students since 2007 (General Office of Beijing Municipality People s Government 2014). Shanghai has also offered free pneumonia vaccine for elderly residents since 2013 (Cai 2013). Many other Chinese cities, however, do not enjoy as much financial resource as Beijing or Shanghai. Some city governments have relied on debts to finance local infrastructures. Guangzhou city, for example, had RMB241.4 billion liabilities in 2012 after hosting the 2010 Asian Games (Xinhua News Agency 2012, unpublished data). These cities need to explore and utilise alternative financial resources to support public health initiatives. One alternative financing avenue for preventive care is social health insurance such as UEBMI, URBMI and NCMS. Currently a few cities including Ningbo have allowed citizens to use UEBMI annual balances to pay for vaccination against seasonal influenza, rabies, pneumonia and hepatitis B for individuals and their close relatives (Chen 2012). Another alternative financing source is from the private sector. The Chinese central government has recognised the vital role of market force, and emphasised the importance of involving the market in health care service provision and in health care financing. Guangzhou City Bureau of Human Resources and Social Security, which is in charge of NCMS schemes, is exploring the possibility of utilising the annual balance through purchasing additional coverage for citizens from commercial insurance firms. Beyond reducing the market price of vaccines through full or partial government subsidies, the other immunisation-related program costs could be shared with the private sector players. For example, multinational vaccine manufactures present in China have been proactive in promoting educational information on influenza prevention and influenza vaccine effectiveness from conducting seminar events, conferences and publicity on mass media. The participation of private sector or civil society on these programs can reduce the financial pressure on local governments. Involving Relevant Stakeholders Policymaking used to be a one-way top-down approach in China. The increased number of

10 Ruan et al.: China s Seasonal Influenza Vaccine Policy 223 platforms for Chinese citizens to participate in the discussion of policies has urged policymakers to involve all relevant stakeholders from the origination of policy proposal to the evaluation of executed policy projects. In formulating immunisation policies, Chinese policy-makers have worked extensively with experts from the WHO to understand global best practices and benchmarks. Interactions with international NGOs and donor agencies such as Global Alliance for Vaccines and Immunization, PATH and the Bill & Melinda Gates Foundation could also provide valuable experiences working with health care professionals, frontline workers and end-users in different countries. Domestically, experts and professionals are engaged through the EACIP to advise the NHFPC on immunisation programs and strategies. Vaccine manufacturers have also been consulted closely by policy-makers especially at the local level to share market intelligence and to understand program feasibilities. Direct communication between policy-makers and end-users is currently limited in China, but it is likely to be increased as Chinese policymakers start to value public feedback and understanding. The media is another critical stakeholder in modern policymaking. Budget constraints may limit some local government s capacity to publicise public health information on conventional media outlets such as television channels. Nevertheless, new media such as the Internet and mobile application is being utilised to promote public health knowledge, and providing information about seasonal influenza. 5. Policy Experiences China is the world s largest developing country with drastic regional differences in living standards, development stages, climate patterns and even cultural backgrounds. Analysis of the seasonal influenza vaccine provision programs in Chinese cities highlights the need for a multipronged approach addressing different policy challenges to achieve the desired policy outcomes. 5.1 Management and Policy-Related Interventions The city-level policymaking process illustrates the importance of providing scientific evidence for policy-makers to evaluate the priority of the agenda and to make more informed policy decisions. Potential policy research focuses for developing countries should include the accurate disease burden calculation, more systematic economic evaluation of vaccine effectiveness and cross-regional comparisons. Meta-analysis and systematic reviews should be encouraged. Data from the existing pilot programs in different cities should be consistently collected, accurately stored and if possible made publicly available for analysis. This requires investment not only in information technology infrastructures, but also in human capital such as frontline health care workers who need to have the motivation and knowledge to conduct these tasks. International experiences on vaccination provision can also be studied to understand the constraining and success factors for the policy programs under different political and economic backgrounds, and adapt those to meet the local needs. Communication of research findings to policy-makers is also critical in the process. Governors in charge of health policies may not acquire as much medical expertise as researchers and health care workers on the specific topics. Their interests often reside in economic and impact evaluations of the programs, rather than epidemiology studies which researchers focus more on. Researchers who aim to raise a policy agenda may need to adapt their findings to meet the needs of policy-makers. Only when information is perceived as relevant and when it is communicated effectively can it lead to policymakers perception and behavioral changes. 5.2 Awareness and Acceptability-Related Interventions The case of Beijing fully subsidising seasonal influenza vaccine for high-risk groups but yet to achieve the WHO recommended immunisation rate shows that financial and access factors are not the only consideration of

11 224 Asia & the Pacific Policy Studies May 2015 consumers. The lack of knowledge and negative misperceptions can impair consumer demand for vaccinations. To increase the demand of seasonal influenza vaccines, interventions targeting at raising awareness and influencing consumer behavior are required. Public education campaigns should focus on closing knowledge gaps including influenza disease risk and burden, mechanism and benefits of vaccines, and the availability of relevant policy programs such as free provision of vaccines for high-risk population. The messages targeting at different groups should be communicated via different channels and platforms. For example, health care workers represent an important target group as their attitudes and knowledge can affect the choices of their patients greatly. Targeting this group of audience requires coordination from Bureau of Propaganda, the Street Committees and the local hospitals. Messages targeting at school-going children can be channeled with assistance of Bureau of Education. The content should be more interactive and fun to attract the attention of the audience. New media such as social media can also be explored. Campaigns targeting adults and elderly should involve more data and expert opinions in order to persuade the target audience to change their mindsets. The communication channels can be newspaper, journals, health-related television shows and posters in residential neighbourhoods. 5.3 Affordability and Access-Related Interventions Programs at the city level in China illustrate that the policy options with most immediate impacts to potentially increase demand for vaccination are related to vaccine affordability and access. Reducing the cost of seasonal influenza vaccination for high-risk individuals, especially for elderly citizens above 60 years old, is proven effective in the case of Beijing to increase the rate of elderly seasonal influenza vaccination especially among rural elderly. If local government budgets are constrained, partial reduction or subsidy will also effective, as it takes a fraction of cost burden off the consumer, thereby increasing consumer surplus. These interventions will require coordination with the Bureau of Human Resources and Social Security, as well as the Bureau of Finance. Other innovative financing methods can also be explored to reduce the financial burden on the local government. Increasing the access to POVs also has high potential to increase the rate of vaccination. POVs at CHCs that are located near residential neighbourhoods should be promoted. The availability of information on adult-related access is important. Tested methods such as door-to-door vaccination on request can also be adopted to make it more convenient for elderly with limited mobility. 6. Policy Implementation Priorities Given constrained resources allocated for seasonal influenza vaccination in many developing nations, priorities among the threepronged interventions are identified in the implementation process as Figure 2 illustrates. Even though affordability of and access to vaccines can directly impact consumer demand in the short term, awareness and acceptability problems are more fundamental. The lack of knowledge about influenza and distrust in vaccine efficacy can undermine demand even if the vaccine program is accessible and affordable. Behavioral change will require accurate information to convince consumers and policy-makers, and will require the generation of knowledge and communication of relevant research findings. Implementation priority should therefore be placed firstly on management and policyrelated policies and secondly on awareness and acceptability-related policies. The short- and medium-term expected outcomes of these activities would be positive changes in the knowledge and attitude of end-users and policy-makers. The long-term outcomes would be positive changes in behaviours, norms, commitment and policy that lead to an increase in the take-up rate of seasonal influenza vaccines. Policy evaluation mechanisms should also be included in program designs before their implementation.

12 Ruan et al.: China s Seasonal Influenza Vaccine Policy 225 Figure 2 Policy Implementation Priorities 7. Conclusion This article identifies a major policy issue of low prioritisation of seasonal influenza vaccinations in China s public health policy. Through the study of city-level programs in China after its recent health care reform, major challenges such as lack of consumer demand, unsustainable program financing and absence of supporting policy environments are analysed. Amidst these challenges, there also exist opportunities in forms of refocusing of policy goals, improving vaccine provision and access, developing evidence-based policies, mobilising alternative resources, and the involvement of relevant stakeholders which can be leveraged upon to promote and increase prioritisation of seasonal influenza vaccination programs. Policy experiences on program designs are identified as a three-pronged approach focusing on (i) management and policy-related interventions, (ii) awareness and acceptability-related interventions, and (iii) affordability and accessrelated interventions. Implementation priorities are recommended to be placed on actions (i) and (ii) that should be undertaken in the immediate period to activate prioritisation, while maintaining a long-term outlook. As China continues on its health care reform agenda, the health care system will remain dynamic. The policy experiences will have to be modified to meet the changing landscape of China s health care sector and be adapted to the varied political, social and economic environments in interested regions and countries. April This research is supported by the Lee Kuan Yew School of Public Policy, National University of Singapore and Sanofi Pasteur (Asia Pacific). Ningzhen Ruan is from Ningde city in China and has lived in Singapore since She holds a Bachelor of Business Administration degree in National University of Singapore, and recently graduated from the Lee Kuan Yew School of Public Policy with a Master in Public Policy degree. Her current research interests include public health care policies, evidencebased policy-making and health care service delivery system designs with market participation. Thao Nguyen holds a Master s degree in Public Policy at the Lee Kuan Yew School of Public Policy, National University of Singa-

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