The investment case for hepatitis B and C in South Africa: adaptation and innovation in policy analysis for disease program scale-up

Abstract

Even though WHO has approved global goals for hepatitis elimination, most countries have yet to establish programs for hepatitis B and C, which account for 320 million infections and over a million deaths annually. One reason for this slow response is the paucity of robust, compelling analyses showing that national HBV/HCV programs could have a significant impact on these epidemics and save lives in a cost-effective, affordable manner. In this context, our team used an investment case approach to develop a national hepatitis action plan for South Africa, grounded in a process of intensive engagement of local stakeholders. Costs were estimated for each activity using an ingredients-based, bottom-up costing tool designed by the authors. The health impact and cost-effectiveness of the Action Plan were assessed by simulating its four priority interventions (HBV birth dose vaccination, PMTCT, HBV treatment and HCV treatment) using previously developed models calibrated to South Africa’s demographic and epidemic profile. The Action Plan is estimated to require ZAR3.8 billion (US$294 million) over 2017–2021, about 0.5% of projected government health spending. Treatment scale-up over the initial 5-year period would avert 13 000 HBV-related and 7000 HCV-related deaths. If scale up continues beyond 2021 in line with WHO goals, more than 670 000 new infections, 200 000 HBV-related deaths, and 30 000 HCV-related deaths could be averted. The incremental cost-effectiveness of the Action Plan is estimated at $3310 per DALY averted, less than the benchmark of half of per capita GDP. Our analysis suggests that the proposed scale-up can be accommodated within South Africa’s fiscal space and represents good use of scarce resources. Discussions are ongoing in South Africa on the allocation of budget to hepatitis. Our work illustrates the value and feasibility of using an investment case approach to assess the costs and relative priority of scaling up HBV/HCV services.

Innovative strategies for the elimination of viral hepatitis at a national level: A country case series

“…To advocate for an adequate allocation of domestic resources and to mobilise external funding support, countries should develop a national plan that sets ambitious but achievable targets, informed by a robust local investment case for viral hepatitis. Gathering accurate data to inform a targeted approach can improve the cost‐effectiveness of specific interventions . Since the launch of the GHSSH 2016‐2021, more countries have developed national hepatitis plans and both local and global investment cases for the elimination of viral hepatitis have been built .…”

“…Gathering accurate data to inform a targeted approach can improve the cost‐effectiveness of specific interventions . Since the launch of the GHSSH 2016‐2021, more countries have developed national hepatitis plans and both local and global investment cases for the elimination of viral hepatitis have been built . Many countries have begun collecting epidemiological data through national seroprevalence surveys or by adding key hepatitis indicators into existing surveillance systems.…”

“…South Africa's National Action Plan 2017‐2021 is one of the first examples of an investment case that combines tools for costing, impact modelling, cost‐effectiveness analysis, and fiscal space analysis for scaled‐up hepatitis B and hepatitis C disease control scenarios . The action plan was developed in collaboration with leading South African experts, Ministry of Health officials, and external specialists in global health policy and economics, who assessed cost and affordability, health impact and cost‐effectiveness for four priority interventions: hepatitis B birth dose vaccination, prevention of MTCT and treatment for hepatitis B and C.…”

“…The model suggests expanded hepatitis B prevention and treatment for hepatitis B and C (using DAAs for the latter) is cost‐effective and affordable in the South African context, noting that hepatitis B birth dose vaccination should be prioritised if funds are insufficient for the full implementation. The five‐year Action Plan was estimated to cost US$270 million, with the “testing, care, and treatment” component being the most costly.…”

“…The modelling data suggest the initial five‐year investment could avert an estimated 13 000 hepatitis B‐related deaths and 7000 hepatitis C‐related deaths. Moreover, a continued expansion of the treatment programme beyond 2021 has the potential to avert 672 000 hepatitis B‐infections and 60 000 deaths averted from hepatitis C‐related liver disease, which would put South Africa firmly on the path to achieve elimination by 2030 (Figure B) …”