Health Affairs, 24, no. 3 (2005): 755-757 doi: 10.1377/hlthaff.24.3.755 © 2005 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

This Article Abstract Reprint (PDF) Submit a response to this article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to Citation Manager Reprints & Permissions Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (4) Citing Articles via Google Scholar Google Scholar Articles by Freed, G. L. Search for Related Content PubMed PubMed Citation Articles by Freed, G. L. Related Collections Consumer Issues Health Promotion/Disease Prevention International Issues Vaccines Public Health Research And Technology

Perspective

PERSPECTIVE

Vaccine Policies Across The Pond: Looking At The U.K. And U.S. Systems

Abstract

 
Major differences exist in the immunization programs of the United Kingdom and the United States. If one believes that most health policy decisions in Western industrialized democracies are political, then many of the differences may seem to reflect the variance in the nature of political systems. However, each program has unique components that appear paradoxical, and what works in one society will not necessarily work in another. Those who seek to substitute portions of one vaccine system with those of another must appreciate the context within which each functions.

Cultural history.

Top Cultural history. Central control. Recommended vaccines. Cost concerns. NOTES

 
Since the industrial revolution, the United Kingdom has had a history of providing social support through government programs for society as a whole. The governmental commitment, both financially and programmatically, to its most vulnerable residents is even stronger. In contrast, the United States is often seen in the paradigm of individualism, in which personal reliance and accomplishment, without assistance or direction from the state, are held in higher regard. It thus can be difficult to reconcile one of the fundamental differences in the immunization programs between the two countries—school and day care entry regulations for immunization.

All fifty states have passed school or day care regulations, or both.² These laws have had a strong and positive impact on immunization rates. No such laws exist in the United Kingdom. In this seemingly paradoxical instance, the United States enforces behavior (immunization) for the public good through legislation, while the United Kingdom relies on the individual’s sense of responsibility to society to promote the same outcome. This has likely come about as a result of the need to consciously limit the usual U.S. model of individual choice when trumped by the needs of society as a whole. Americans might be more likely to think of their rights as individuals first and of their responsibility to society second, thus requiring governmental intervention at specific points to ensure that the needs of society are met. It is likely that Britons’ commitment to society is strong enough to obviate the need for such legislation.

However, when serious concerns regarding vaccine safety arise, the potential weakness of the U.K. system becomes evident. Under such conditions, the focus of the population transforms to become one of individual and personal apprehension for one’s child. Without the already accepted, overriding legislative directive as present in the U.S. system, attempts to then actively encourage immunization may be seen as coercive by the state. Although concerns regarding the measles-mumps-rubella (MMR) vaccine were also prominent in the United States, immunization rates did not then fall, contrary to the U.K. experience.

Central control.

Top Cultural history. Central control. Recommended vaccines. Cost concerns. NOTES

 
In other instances, the British perspective and policies appear to make for a more efficient system. For example, although debate on a single-payer system is beyond the scope of this discussion, vaccine financing in such a system has distinct advantages over the free-market U.S. system. The U.S. system of vaccine financing is a patchwork of public and private funding, which requires a cumbersome, and at times duplicative, distribution and storage system for private-sector providers.³ In the United Kingdom, the purchase and distribution of vaccines are managed centrally, under a single governmental budget and administrative authority. The British system also allows for true national coordination of vaccine supply in times of absolute or relative shortages, something sorely lacking in the United States. Further, the ability to keep a reserve in place, as David Salisbury describes, helps prevent interruptions in supply.

The U.K. system also clearly simplifies vaccine availability for the entire child population. Government-recommended vaccines are given in the office of any National Health Service (NHS) provider at no charge. This is in stark contrast to the U.S. system, in which there are sometimes complex eligibility requirements for children to participate in government-funded vaccine purchase programs. Eligibility also differs from state to state, thus creating a differential in access across the country.⁴

Central government purchase of vaccines has other advantages, including the ability to influence providers’ behavior by providing only specific vaccines for use. Although this mechanism is well accepted in the United Kingdom, U.S. principles, the tradition of the free market in health care, and the culture of provider independence make such a system antithetical to U.S. policymakers. Many states even have passed specific legislation requiring that individual providers have a choice of manufacturers for public sector–purchased vaccines for use in their practices.

Recommended vaccines.

Top Cultural history. Central control. Recommended vaccines. Cost concerns. NOTES

 
The processes by which immunization recommendations are formulated in the two countries also differ. Although both rely on expert committees appointed by their respective governments, these committees function differently. The U.S. Advisory Committee on Immunization Practices (ACIP) is subject to the federal Open Meetings Act and holds its meetings in public. In contrast, the meetings of the U.K. Joint Committee on Vaccination and Immunization (JCVI) are by invitation only and closed to the public. The concept of open meetings is of prime importance to the U.S. political landscape. The public trust in the U.S. immunization program would suffer markedly if such a system were not in place. Although participants might feel that more candid deliberations can take place in a closed session, the image portrayed to the public can be one of something to hide. The closed system in the United Kingdom may have contributed to a greater distrust of the immunization program, thus limiting the effectiveness of efforts to allay fears regarding specific vaccine concerns. If such a system were in place in the United States, public distrust would be the likely outcome.

Cost concerns.

Top Cultural history. Central control. Recommended vaccines. Cost concerns. NOTES

 
Although both countries struggle with the increasing cost of new vaccines, the constraints under which each operates differ considerably. If the ACIP recommends a vaccine for use and subsequently recommends that it be made a part of the U.S. Vaccines for Children (VFC) program, the federal government, through an entitlement funding stream, will then cover the cost of the vaccine for more than half of U.S. children.⁵ Although the ACIP considers the cost of the vaccine, decisions are not made with this as a primary issue. Additionally, there is no central role for the secretary of health and human services in this process, and the funds do not come from the secretary’s discretionary spending budget. Thus, there is little or no incentive for the secretary to set up barriers to the inclusion of new vaccines into the immunization schedule. The remainder of U.S. children must then have their vaccines purchased either by state governments, by private insurance, or from out-of-pocket spending. Frequently, the ACIP recommendation is the catalyst for the other payers to cover the vaccine. However, there is often a delay in this process so that some children have coverage for a new vaccine while others do not.⁶

In the United Kingdom, budgetary constraints seem to play a stronger role in the decision to include a new vaccine in the recommended schedule. For a new vaccine to be included, the minister of health must commit funds within his current budget or enter into negotiations with the Finance Ministry to secure additional funds. Efforts to introduce new vaccines must compete with similar efforts to add other products to the basket of government-provided services. An informal threshold of cost-effectiveness is used to justify the expense of new vaccines in the system. If a vaccine cannot be shown to at least approximate this threshold, it stands little chance of becoming part of the national program. However, once funds are committed, they are committed for the entire population covered by the recommendation.

There are also some substantive differences in the immunization schedules recommended by the ACIP and JCVI that do not involve issues of vaccine financing. Most are a product of the different epidemiology of specific diseases on either side of the pond. For example, the U.K. schedule recommends provision of the meningococcal C vaccine as part of the primary immunization series from birth to six months, to prevent serious cases of meningococcal meningitis among very young children. In the United States, the ACIP recently recommended the vaccine for use in adolescents and college-age youth—the ages at which the disease strikes in the United States.

The two systems are likely good "fits" for their respective constituencies, as both operate successfully within their countries’ social and political frameworks. With the exception of MMR vaccination in the United Kingdom, both countries meet or exceed their national immunization goals. Nevertheless, what works in one society will not necessarily work in another. Those who seek to substitute portions of one vaccine system with another must appreciate the context within which each functions and the part it plays in the entire health care and political system.

Editor's Notes

 
Gary Freed (gfreed{at}med.umich.edu) is director of the Child Health Evaluation and Research (CHEAR) Unit and director of the Division of General Pediatrics, University of Michigan, in Ann Arbor.

This work was funded, in part, by a grant (F33 A1062016-01) from the National Institute for Allergy and Infectious Diseases.

NOTES

Top Cultural history. Central control. Recommended vaccines. Cost concerns. NOTES

 

1. See D.M. Salisbury, "Development of Immunization Policy and Its Implementation in the United Kingdom," Health Affairs 24, no. 3 (2005): 744–754[Abstract/Free Full Text]; W.A. Orenstein et al., "Immunizations in the United States: Success, Structure, and Stress," Health Affairs 24, no. 3 (2005): 599–610[Abstract/Free Full Text]; and J. Colgrove and R. Bayer, "Could It Happen Here? Vaccine Risk Controversies and the Specter of Derailment," Health Affairs 24, no. 3 (2005): 729–739.[Abstract/Free Full Text]
2. A.R. Hinman et al., "Childhood Immunization: Laws That Work," Journal of Law, Medicine, and Ethics 30, no. 3 Supp. (2002): 122–127; and W.A. Orenstein and A.R. Hinman, "The Immunization System in the United States: The Role of School Immunization Laws," Vaccine 17, no. 3 Supp. (1999): S19–S24.
3. Orenstein et al., "Immunizations."
4. Ibid.
5. W.A. Orenstein, L.E. Rodewald, and A.R. Hinman, "Immunization in the United States," in Vaccines, 4th ed., ed. S.A. Plotkin and W.A. Orenstein (Philadelphia: W.B. Saunders, 2004), 1357–1386.
6. Orenstein et al., "Immunizations."

                      What's this?

This article has been cited by other articles:

				G. Horlick, F. E. Shaw, M. Gorji, D. B. Fishbein, and for the Working Group on Legislation, Vaccination Delivering New Vaccines to Adolescents: The Role of School-Entry Laws Pediatrics, January 1, 2008; 121(Supplement_1): S79 - S84. [Abstract] [Full Text] [PDF]

				F. P. Rivara and D. A. Christakis The March of Science Arch Pediatr Adolesc Med, December 1, 2007; 161(12): 1214 - 1215. [Full Text] [PDF]