Removing cost barriers
The importance of reducing costs for testing
The WHA global survey found that out-of-pocket costs to patients were one of the principal barriers to diagnosis. To date, viral hepatitis testing costs have mainly been approached from a provider rather than user perspective in WHO initiatives (WHO, 2017b). However, the 4th strategic direction of the GHSS is:
“Financing for sustainability: proposing strategies to reduce costs, improve efficiencies and minimize the risk of financial hardship for those requiring the services” and the proposed priority actions for countries include reducing financial barriers to patients by phasing out direct, out-of-pocket payments (WHO, 2016). A coordinated and decided approach to curb this barrier is needed and civil society and the affected community can contribute by:
Hepatitis testing and treatment to be included in universal health coverage (UHC) efforts, as set out by the Universal Health Coverage Forum in the Tokyo Declaration (2017)
1. Make the case for hepatitis showing that it is cost effective and often cost saving. Furthermore, addressing hepatitis will strengthen health systems.
- Look at the global investment case for hepatitis B and C (or the summary here) and the WISH report on Viral Hepatitis.
- Learn more about UHC by watching this short video by WHA CEO, Cary James
2. In those countries that still have some way to go to achieve UHC you can take a staged approach. While pursuing opportunities to include hepatitis testing and treatment in UHC, urge governments to target small-scale/short term funding towards activities that can be used to demonstrate political will, build initial testing infrastructure, and generate evidence for effective programme scale-up once sustainable funding is secured.
Prof. Ammal Mokhtar Metwally, National Research Centre of Egypt, speaks about how Egyptian Liver Research Institute and Hospital (ELRIAH) in collaboration with the National Research Centre of Egypt, implemented an innovative programme to achieve hepatitis C micro-elimination and make the village of Al-Othmanya the first “village free of hepatitis C” in Egypt.
No, or limited and easily affordable, out-of-pocket costs for patients through inclusion of viral hepatitis services in health insurance schemes
1. Where relevant, focus messaging on the fact that most infections were acquired through the health care system and so people should not have to pay to be tested.
2. Look at what other countries are doing and use comparisons to make your case, countries that may be good to look at in the first instance are Australia and Mongolia.
- If there is not a country case study which is relevant to the size, governance and financial capability of your country you could instead look at micro-elimination projects which have been conducted either within your country or countries with a similar profile to yours. Micro-elimination projects can help to better illustrate the investment required and the economic and health outcomes of addressing viral hepatitis.
Naranbaatar Dashdorj, Chairman of Board of Onom Foundation, speaks about how patients and civil society in Mongolia used advocacy to establish a lobby group within the parliament, initiating the Hepatitis Prevention, Control, and Elimination Program and most importantly, ensuring that it was funded through health insurance. Find out more here.
3. Build the evidence base by surveying people living with viral hepatitis to determine what impact free or cheaper testing would have on their ability to access services. Use this to help shape your arguments on the benefits to both the individual and the health system.
Swiss Hepatitis C Association conduct surveys with PWID’s to find out what impact free or cheaper testing would have on their ability to access services. Find out more here.
4. Create a petition demanding the government provide free, or easily affordable, access to hepatitis diagnostics and treatment for all citizens.
The use of central procurement of quality-assured and affordable tests in order to obtain price-volume agreements
1. Central procurement is the purchase of all quality-assured tests by one office or department within a country in order to drive down costs. Countries within a region can also come together to obtain price-volume agreements through pooled procurement. You can learn more on pooled procurement by looking at the information on the National Viral Hepatitis Programme Financing Strategy Template This looks at different mechanisms for pooled procurement and will help build your evidence base.
2. Speak to the Ministry of Health, diagnostic manufacturers and other stakeholders to ensure price transparency/pricing data for diagnostic assays and platforms is available. This will assist in advocacy efforts to procurement authorities for better price negotiations.
Leveraging of existing services in order to decrease investment costs for testing infrastructure and personnel, e.g. within HIV or other settings
1. Speak to policy makers and programme directors about integration and the importance of using integrated approaches to testing. For example, much of the infrastructure required for viral hepatitis elimination can be effectively added to existing HIV, TB and syphilis programmes at little additional costs.
- See Georgia and Rwanda case studies.
- You could also explore integration with non-communicable diseases such as diabetes. In Egypt their screening programme for hepatitis C, also includes an assessment for hypertension, diabetes and obesity.
Note: policy makers and programme directors will need to ensure that clear guidance to microbiologists/lab technicians is put in place to facilitate and prioritise viral hepatitis diagnosis.
2. Push for HIV and other disease budgets to have a specific budget line for viral hepatitis. This will enable tracking of how viral hepatitis is funded and meeting the needs of the patients. For example, hepatitis education/training can be provided to HIV outreach workers but there should be consideration for budgeting of additional staff and peer educators to improve linkage to care.
3. Speak to donors for HIV and TB programmes and advocate for them to allow testing platforms with capacity, and the ability to test hepatitis assays, to be used for hepatitis testing.
4. Look at task-shifting and task-sharing opportunities i.e.: having a more coordinated approach amongst the health, research and community settings.
- See guidelines that support this approach such as WHO’s Global Health Sector Strategy on Viral Hepatitis, WHO’s Task Shifting Global Recommendations and Guidelines and other relevant guidelines.
Action you can take
As well as advocating for change you can also take action yourself. The below suggestions could help you to accelerate momentum to Find the Missing Millions and eliminate hepatitis.
(a) Be a part of multi-stakeholder initiatives at the national level to inform the negotiation of pricing for diagnostic technologies and services
(b) Assist in collecting and monitoring pricing data