Charting a New Course to Hepatitis Elimination in Pakistan

Approximately 10 million Pakistanis are living with hepatitis C (HCV) with three people dying of HCV- related causes every minute – and this in the case of a disease that is now largely curable with treatment.

Hepatitis B Virus (HBV) also poses major public health burden on the country’s health system with an estimated 4 million active infections in the population. Transmission is largely driven by infections acquired from healthcare settings, which puts the wider population at risk.

Altogether, it’s estimated that more than 20,000 people a year die in Pakistan from hepatitis-related causes.

WHO’s strategy for Elimination of Hepatitis refers to a 90% reduction in new HBV infections and a 75% reduction in new HCV infections by 2030 over the 2020 baseline, and a 65% reduction in overall mortality. The Sustainable Development Goals (Target 3.3) meanwhile, call for “combating hepatitis” by 2030.

Great strides could be made towards these WHO and SDG goals with the uptake of new strategies for bringing hepatitis diagnosis and treatment to the primary and district care levels. This also would save families the heavy burden, and public hospitals the high-costs, of later stage treatment.

Hepatitis isn’t treated as a priority disease

Pakistan, a range of health systems challenges have contributed to sluggish progress towards disease elimination to date.

First and foremost, due to lack of effective and strategic advocacy, hepatitis does not get much attention from policy and decision makers. This is reflected in the resources being directed towards the programs of competing priorities. The primary diseases of public health focus remain dengue, polio and tuberculosis – which in fact account for far fewer deaths when compared to hepatitis B and C.

As a result, there is little incentive to expand public health hepatitis services, leading to disparity in demand and supply of hepatitis screening, vaccination, and treatment services – treatment that can lead to cure for those living with HCV. Additionally, private treatment remains expensive and out of reach for the majority of the country’s population.

Lack of access to diagnosis and care services

Provincial hepatitis control programs exist but there is a large variability in successful program implementation across Pakistan’s provinces.

The infrastructure of provincial hepatitis programs is centralized and mostly limited to hepatitis clinics that are located at tertiary healthcare facilities, i.e. hospitals.

The access to preventive, diagnostic and treatment services for impoverished and marginalized communities that are at the highest risk is more difficult. Even for those who manage to access the central healthcare system, the pathway from screening to treatment acquisition is hard to navigate and time consuming.

Notably, a PCR assessment of viral load remains the standard for a confirmed diagnosis, and this only available through a limited number of labs. Provincial hepatitis programmes must bear the cost of transportation and quality management of samples, along with testing people with suspected cases. For a patient, the process from tet to results can take days and sometimes weeks. This system consumes the resources in ineffective way.

Public hospitals saddled with high costs of acute disease treatment

The shortcomings of the hepatitis control programs are reflected in the consequently high burden of liver disease and costs associated with treating ‘decompensated liver disease’, where acute symptoms develop, as well as liver failure and liver cancer, in tertiary care hospitals.

This requires resources to be spent on specialized gastroenterology and hepatology healthcare. In addition, the patients must bear out-of-pocket costs for expensive CT scans, tests of tumor markers, etc. This imposes a significant financial toll on families, who therefore are likely to end up in government hospitals due to lack of affordability.

Needed – large scale decentralization and door-to-door models

To combat hepatitis in Pakistan, a program overhaul is therefore needed – so as to bridge the existing gap between public health and clinical medicine. This involves drafting a comprehensive national action plan that holistically addresses all components of the disease epidemiology, as well as harnessing available resources, and implementation science more effectively.

The action plan must provide for the large-scale decentralization of hepatitis care alongside a pattern of ‘differentiated’ service delivery. This means establishing structures allowing people to be treated in community primary facilities and district-level secondary facilities at earlier stages of infection and disease – with more complicated cases referred to hospitals for more complex tertiary care.

For communities with a high burden of infection, small scale micro-elimination programs using a door-to-door elimination model can be implemented. This also requires agreement to an effective, ‘needs-based’ utilization of resources, with some sharing of commodities and human resources, from other successfully running programs at district level.

Combating under-diagnosis

Along with that, establishing a strong, hierarchal surveillance system for HBV and HCV infections is the need of the hour.

Underdiagnosis of hepatitis is a barrier to elimination. But this can be addressed with the use of new and innovative surveillance tools and technologies to generate quality data and support evidence-based decision making.

Strategic advocacy and communication must be included in the action plan to improve risk perception and community health literacy about bloodborne infections.

And most important of all, end user involvement in drafting the national plan is a must with the feedback from primary care providers and frontline health workers to tailor the program based on community needs.

On World Hepatitis Day 2019, the national government announced a PKR 35 billion ($125 million) investment in hepatitis control, launching a National Hepatitis Elimination initiative. The plan aims to screen up to 140 million people and expand treatment to those infected.

It’s still far too little to cure the millions living with hepatitis. But it remains a beginning, showing high-level political commitment. But pledges alone are not sufficient. The dire need is to make hepatitis elimination a national priority with a strategic shift in governance and policy and ensuring the intelligent expenditure of resources.

By Dr Nida Ali
Dr Nida Ali is a fellow with the Coalition for Global Hepatitis Elimination, a program of the Task Force for Global Health. The Coalition pursues worldwide elimination of viral hepatitis by strengthening local capacity and bringing together global partners to share knowledge and experiences related to prevention, testing, and care and treatment.

Source: Health Policy Watch