Cervical cancer is a highly preventable and treatable disease, yet it remains the world’s fourth most common gynaecologic cancer [1] and poses a significant burden in China, where an estimated 170 women die from cervical cancer every day [8]. The newly prequalified domestic bivalent HPV vaccine offers a practical and feasible preventive measure. It has been estimated that including the domestic vaccine in immunisation programmes is cost-effective both at the national level and in most provinces of China [31]. Nonetheless, despite the goal of vaccinating 90% of girls by the age of 15 by 2030, implementation of the HPV vaccination for eligible girls has been patchy across the country, with the overall vaccination coverage remaining extremely low.

Since 2020, pilot HPV vaccination programmes have been initiated in a number of cities, offering free HPV vaccines or vaccination subsidies for school-aged girls. The present case study highlights several critical factors contributing to the success of implementing the free HPV vaccination for eligible girls in Shenzhen, including strong governmental commitment backed with sufficient funding, active participation of multiple governmental departments, available and affordable vaccines, high-quality vaccination services, and improved public awareness. Comparing to implementation strategies adopted in many other parts of China, which mainly focused on provision of free vaccines and education to adolescents and their parents [11, 24, 32], Shenzhen introduced a holistic model that involved extensive policy advocacy activities, strong governmental leadership and clear accountability mechanisms, centralised procurement and streamlined distribution of the domestic vaccine, tight collaborations between schools and vaccination clinics, informatisation of vaccine administration, as well as targeted public educational campaigns.

However, when compared to cities like Jinan and Chengdu, where over 90% of eligible girls were vaccinated within 2 months [14, 15], Shenzhen’s free vaccination rate of 82.1% appears relatively lower. This discrepancy can be attributed to several factors. Firstly, in Jinan and Chengdu, HPV vaccination was extended to girls aged below 15 in Grade 7 and girls aged 13 to 14 at school, respectively. In contrast, Shenzhen’s Work Guidelines focused on vaccinating girls aged below 14 in Grade 7, potentially missing those who started school early. Moreover, centralised procurement of the HPV vaccine at the provincial level of Guangdong, as opposed to city-level procurement in Jinan and Chengdu, could have resulted in delays and logistical challenges in distributing the vaccine efficiently to vaccination clinics, impacting Shenzhen’s ability to rapidly reach a higher coverage.

While case studies in this domain remain limited, this in-depth analysis of Shenzhen’s experience offers a valuable reference point for understanding the intricacies of implementing the HPV vaccination for eligible girls at local level of China. Lessons learned from the demonstration project can provide valuable insights for future advocacy and implementation in other areas of China, particularly those have not yet initiated the vaccination. To begin with, given the rapid increase in the HPV vaccination rate among Grade 7 girls in Shenzhen after the municipal government began actively addressing it, it is imperative for local health agencies, professional societies, and non-governmental organisations to engage in more active, advocacy-oriented outreach to stimulate policy and funding attention. This aligns with findings from a policy analysis conducted in 2019, which suggested that the lack of powerful advocates and health professionals’ mobilisation skills hindered the feasibility of universal HPV vaccination in Shenzhen [33]. Advocacy efforts are more likely to succeed when advocates are tightly coalesced and able to transform international norms and up-to-date evidence into political influence, and link the issue to national political priorities, such as the Healthy China Initiative, thereby pressuring the local government to take action [34, 35]. The involvement of influential individuals, such as Prof. Youlin Qiao, and partnerships with networks focused on vaccine equity, like the Bill & Melinda Gates Foundation, present significant opportunities for effective advocacy [33, 36].

Additionally, strong governmental leadership and effective coordinating mechanisms are essential for achieving policy goals [35]. For the HPV vaccination for eligible girls, robust accountability frameworks should be established, building on existing immunisation and adolescent health infrastructures, to promote transparency, accountability, and collaboration at all levels. The demonstration project exemplified the effectiveness of clearly defined responsibilities for all participating sectors, which facilitated joint decision-making and collaborative implementation, particularly between CHSCs and schools, leading to the rapid expansion of vaccination coverage. This finding is consistent with existing literature that the most acceptable approach to improve vaccination uptake is through voluntary school-based vaccination programmes. For example, Lee and colleagues reported that a Home-School-Doctor model would improve adherence to HPV vaccination among adolescent girls and their parents even when they need to pay in Hong Kong, China [37].

Furthermore, Shenzhen’s experience underscores the importance of combining public educational initiatives with community outreach, such as the “Expert-into-School”, to enhance awareness and acceptance of HPV and HPV vaccine among parents, students, and school administrators. Targeted messages and tailored approaches effectively addressed specific concerns and misconceptions related to the domestic vaccine. Moreover, integrating health education on HPV into existing school-based sexual health curriculum through collaborations between schools and public health agencies proved instrumental in rapidly increasing positive attitudes towards the vaccination programme within a short time. This is consistent with experiences in other cities, as demonstrated in Zhang and colleagues’ multi-center intervention follow-up study, where a “Train-the-Trainer” approach significantly increased HPV-related knowledge and vaccine acceptability among adolescents [24].

The demonstration project also highlighted several challenges that must be addressed to further implement and sustain the progress. Firstly, vaccine hesitancy among parents and guardians due to concerns about the domestic vaccine’s safety and efficacy, coupled with limited knowledge about HPV vaccination, remains a significant obstacle. Notably, a recently published systematic review on HPV vaccination promotion interventions by Escoffery et al. emphasised the need to expand promotion efforts beyond educational interventions [38]. In this context, multi-component, multi-level and system interventions, targeting both individual behaviours and healthcare provider practices should be designed and evaluated [39].

Secondly, expanding the HPV vaccination programme to achieve universal coverage is a major challenge. Currently, the vaccine is only free for Grade 7 girls aged below 14, which leaves out many adolescent girls who are at risk of HPV infection. Moreover, girls who do not attend school are unable to access the vaccine, which limits the programme’s reach and effectiveness. To address these challenges, there is a need to develop innovative strategies to catch up with girls who missed the vaccine, especially those from vulnerable populations, and to expand the programme to cover a broader age range [40]. This could involve establishing public-private partnerships and a multiple funding mechanism, as well as engaging community health workers to improve vaccine access and uptake among hard-to-reach populations [41]. For example, a recently published randomised controlled trial by Li et al. reported that an innovative “Pay-it-Forward” approach, where participants received subsidised vaccines had the chance to donate to support others get vaccinated, significantly increased HPV vaccination uptake among girls aged 15–18, with a 98% uptake rate in the intervention group compared to 82% in the control group [42]. However, such efforts require a strong commitment from the government and stakeholders, as well as sustained funding and resources to ensure the sustainability and scalability of the programmes.

Thirdly, the applicability of Shenzhen’s experience to other areas of China is uncertain due to differences in economic development levels and healthcare systems. In an earlier health policy analysis, Chen et al. suggested that introduction of the HPV vaccination for eligible girls in Shenzhen was shaped by local legislative environment, economic development level, and social norms on immunisation and sexuality [33]. Therefore, it is important to conduct further research to understand the contextual factors that may impact implementation of the vaccination in different settings. Future research should also assess the long-term effectiveness of the vaccination programme, including its impact on the incidence and mortality of cervical cancer, and conduct health economic evaluations to support its expansion to other places. Given the dearth of case studies on implementing the HPV vaccination for eligible girls in China, this study not only contributes to address the research gap but also highlights the potential for applying the case study method in other cities. Cross-city case studies can enable comprehensive comparisons and enrich the knowledge base, ultimately facilitating the development of effective vaccination strategies.

Lastly, ensuring consistent quality of vaccination services in primary care facilities is crucial for the success of the HPV vaccination programme. Given that practitioners in private facilities had relatively poor knowledge of HPV and HPV vaccine, measures should be taken to ensure that they receive adequate training and resources to provide high-quality vaccination services. Future research should examine the drivers and obstacles to implementing the HPV vaccination for eligible girls at the primary care facility level, which will inform the design and testing of intervention strategies to optimise implementation. Such strategies could include targeted training and education programmes for practitioners, the establishment of quality assurance mechanisms, and incentivisation [38].