From Local Pilots to National Implementation: A Journey Towards Free HPV Vaccination in China.

China recently became the 155th country to provide free vaccination to all 13-year-old girls with two doses of a domestic bivalent HPV vaccine in October 2025. Such a policy change aligns with the Immunization Agenda 2030, which expects more investment of domestic resources into immunization rather than heavily depending on external donor funding support. This review examines the policy-making evolution process and analyzes how the final decision was made at the national level, using the Multiple Streams Framework. Unlike traditional NIP expansion, which adopts a top-down decision-making strategy, China's free HPV vaccination policy evolved with a distinct bottom-up strategy originating from local pilots, which is demonstrated to be instrumental for national policy-making. The extensive local pilots of free HPV vaccination have served as a powerful engine that drives a rapid and substantial increase in HPV vaccination rate, played a pivotal role in shaping the market of HPV vaccines, and contributed to achieving the economies of scale, which triggered a substantial price reduction. It also fostered a national consensus on the critical role of HPV vaccination in cervical cancer prevention and control, a principle now enshrined in the core public health knowledge repository across the country. A potential strategy to introduce new vaccines into the NIP could be piloting first and expanding incrementally with the bottom-up strategy, leveraging a comprehensive platform under the framework of the national policy, and then making use of the effect of scale and peer pressure, high level engagement, cross-departmental collaboration, and multiple financing mechanisms.