Putting money on the table: Nigeria’s policy response to hepatitis B and C
Putting money on the table: Nigeria’s policy response to hepatitis B and C
Nigeria has seen a steady increase in the prevalence of viral hepatitis over the past few decades. The introduction of a routine immunisation programme in 2004 for hepatitis B contributed to a drop in the overall rate of hepatitis infection in children; the number of cases in adults continues to rise.1
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Sustaining the push to elimination and beyond: Rwanda’s policy response to...
For decades, Rwanda has battled significant levels of hepatitis B (HBV) and C (HCV) infections. Sidonie Uwimpuhwe, Rwanda’s Country Director at the Clinton Health Access Initiative (CHAI) reports that an estimated 4% of the population were with living with HCV, whilst HBV prevalence was around 2% when the programme started. The burden is more pronounced in those over the age of 55, where HCV prevalence rises to 16%.1 The scale of infection is also slightly higher in vulnerable populations, such as those living with other conditions like HIV. Since HIV, HBV and HCV share transmission routes, prevalence of coinfections with HIV continues to be an issue. In 2017, a study found that the prevalence of HBV and HCV antibodies in people living with HIV were 4.3% and 4.6% respectively. Although antibody testing cannot confirm a chronic HBV or HCV infection, the study highlighted that these figures acted as a good proxy for chronicity.2
The 1994 genocide, saw health facilities and workforce severely impacted.3 The genocide claimed over a million lives and is thought to have led to widespread hepatitis transmission due to mass casualties.2 Thousands were also raped and exposed to HIV or HCV.4 Alongside exposure to contaminated blood during this period, unsafe needle use, dental care and past traditional practices led to higher transmission rates within the population. This contributes to today’s high caseload of hepatitis, especially in older people.
There is little difference in rates of HCV infection between urban and rural areas. Rates of HBV, however, are higher in the rural communities, with transmission from motherto-child, between household members and families being the main drivers.4 Prior to the introduction of direct-acting antivirals (DAAs) in 2014, people with HCV were treated with a series of interferon injections, which were expensive, ineffective (only about 40% of patients responded) and had major side effects.5
Building back the health system
The country was forced to build back its health system after its civil war and created ambitious plans to restore health services. Vision 2020 is a government development framework launched in 2000, with the objectives of reducing poverty, health problems and uniting the nation.6 Leadership at national and local levels was maintained during partnerships with non-governmental organisations to ensure that foreign aid was used in line with national strategies.7, 8
Facing a workforce crisis, emphasis was placed on increasing the numbers of health professionals by training physicians and nurses.9 A performance-based financing system was launched in 2005 to reward community health centres and district hospitals for better patient follow-up and primary care indicators, thus improving existing services.9
Ensuring that the population could access healthcare was recognised as a key mechanism to reduce poverty. A national mutual health insurance scheme, mutuelles de santé, was piloted in 1999.9 The most vulnerable citizens were enrolled into national social protection programmes and fully subsidised communitybased health insurance schemes (CBHI). In 2012, over 90% of the population was covered by insurance, that figure is now at 95%, and costs zero to a few dollars per year for individuals.10, 11
Keeping up the momentum: hepatitis prevention, testing and treatment
Using the momentum from the post-genocide health system rebuilding, Rwanda increased its activities towards tackling its hepatitis epidemic. In 1999, Rwanda introduced screening for HCV in recognition of its largely asymptomatic nature.12 The hepatitis B vaccine was introduced into the country’s expanded programme of immunisation (EPI) in 2000 in recognition of growing prevalence.13 Dr Sabin Nsanzimana, Director General of the Rwanda Biomedical Centre, adds that a birth-dose HBV immunisation programme is due to be introduced in 2021.
As part of prevention efforts, the Ministry of Health has introduced annual mass-media campaigns to raise awareness of hepatitis and mass screening in the general population and
“Rwanda’s viral hepatitis interventions are not part of a standalone programme. Everything is being built on top of existing infrastructure within the health system.”
Dr Sabin Nsanzimana
reduce stigma. The campaigns are delivered through community health workers, media outlets such as radio and television, and churches.14 The Ministry of Health also ensures that health practitioners are provided with training and education about risk reduction for exposure to hepatitis, infection control measures and implementation of the national clinical guidelines.15
To quantify the burden of hepatitis, robust screening and testing programmes are required. In 2013 Rwanda scaled up capacity for HCV testing by using existing HIV programmes, testing platforms and laboratory systems. All hospitals were provided with WHO-prequalified rapid diagnostic tests for HCV-antibody detection.16 National guidelines recommend that all adults are tested at least once, with annual testing for anyone with potential exposure to HCV infection. High risk groups are also recommended to undergo annual testing and pregnant women are advised to receive systematic testing. Screening and testing for HCV is currently available in multiple settings within hospitals, including antenatal care appointments, outpatient departments and blood transfusion centres.17
The reduction of financial and geographical barriers promotes access to health services and contributes to the success of any plan or programme. The Rwandan government has consistently negotiated price reductions for rapid diagnostic tests and treatments; it has also prioritised the inclusion of HCV screening, diagnosis and treatment under both public and private health insurance schemes.18 Dr Emmanuel Musabeyezu, a key player in the establishment of the hepatitis programme in Rwanda and a specialist in hepatitis management, highlighted the importance of coverage of hepatitis care under the public system, with people more likely to use the services and get tested if they do not have to pay.
In the past, people living with HCV in Rwanda were only treated by a small number of specialists. However, Rwanda has adopted a public health approach and decentralised health services away from specialists to general practitioners at the district level as part of scaling-up services.19, 20 Dr Musabeyezu explained that enables screening, viral load testing and treatment in a location convenient to individuals. This move has improved accessibility for patients and extended services to geographically hard-to-reach populations that would otherwise go untreated.
Rwanda’s aggressive approach to combating viral hepatitis is paying off. By the end of 2018, approximately 700,000 people were screened for HCV and 10,000 were cured with treatment.
“When you feel you are achieving something, it makes you work harder.”
Dr Emmanuel Musabeyezu
A bold and holistic elimination plan
Rwanda is one of the few countries in subSaharan Africa that has managed to achieve most of the health-related Millennium Development Goals, including noteworthy accomplishments in maternal and child health, control of HIV, tuberculosis and malaria.22
In 2018 Rwanda set its sights on a new challenge, committing to eliminating hepatitis C by 2024. It was the first country in subSaharan Africa to propose a five-year HCV elimination plan that included initiatives such as raising community awareness, ensuring affordability of screening and treatment, and solidarity with international partners.23 If Rwanda achieves its goal, it will have done so six years ahead of the 2030 global target for elimination set by the World Health Organization.2
Spurred on by the elimination plan and building on the significant progress already made towards the goal, Rwanda started work on refining and scaling up its existing hepatitis services. Due to the substantial improvement in the affordability of screening tests, demand for screening has increased rapidly. The Rwandan Ministry of Health harnessed this opportunity to use the HCV screening programme to also screen people for HBV.24 This has been facilitated by the introduction of a new rapid diagnostic test that can be offered at the point of care, produces results in twenty minutes and costs just US$1, reduced from US$30.
The Rwandan government recognised that access to treatment plays a major role in the uptake of screening. It negotiated further reductions in treatment costs from US$80,000 to US$60. The reductions in medications costs were also a result of the fall in prices of generic medicines. The total estimated cost for the five-year plan was US$113m, but these dramatic savings mean the program cost is now predicted to be US$43m.25
In addition to the geographical expansion of screening and testing sites to remote areas of the country, Rwanda is working towards training more physicians and nurses to be able to prescribe and monitor DAA treatment. Basing this initiative on a previous strategy for HIV control, the diagnosis and treatment of simple cases of HCV will be shifted from specialists to primary care doctors and nurses. Individuals with complications will still be referred to specialists.4
Final push to elimination: ensuring sustainability
Dr Musabeyezu highlights that Rwanda now faces the challenge of ensuring that the increasing number of people attending screening are linked to appropriate and high-quality care. At a system level, there is a need to ensure good supply management for medications to prevent or mitigate shortages. Programme monitoring and evaluation enables programmes to improve over time. To support this process, Ms Uwimpuhwe says CHAI is working with the Rwandan government to strengthen existing infrastructure, increase the skills of health workers through strong training and mentorship programs, as well as supportive e-learning tools and strong digital solutions to improve patient management and support.
Looking forward, Rwanda needs to continue working on improving accessibility to services in remote areas. Engaging with religious leaders, local government and the private sector will play a critical part in its success. Dr Nsanzimana adds that the government is exploring including hepatitis services in Rwanda’s CBHI.
Rwanda continues to pave the way towards viral hepatitis elimination and the learnings from its journey—characterised by sustained political commitment and investment, with innovative integration of services—will provide valuable insights for other countries in the region.
While every effort has been taken to verify the accuracy of this information, The Economist Intelligence Unit Ltd. cannot accept any responsibility or liability for reliance by any person on this report or any of the information, opinions or conclusions set out in this report. The findings and views expressed in the report do not necessarily reflect the views of the sponsor.
[1] Clinton Health Access Initiative. 2020. Partnerships Will Help Rwanda Eliminate Hepatitis C In Five Years - Clinton Health Access Initiative. [online] Available at: https://www.clintonhealthaccess.org/partnerships-will-help-rwanda-eliminate-hepatitis-c-in-five-years/
[2] Umutesi, J., Simmons, B., Makuza, J., Dushimiyimana, D., Mbituyumuremyi, A., Uwimana, J., Ford, N., Mills, E. and Nsanzimana, S., 2017. Prevalence of hepatitis B and C infection in persons living with HIV enrolled in care in Rwanda. BMC Infectious Diseases, [online] 17(1). Available at: https:// bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-017-2422-9.
[3] Mbituyumuremyi, A., Van Nuil, J., Umuhire, J., Mugabo, J., Mwumvaneza, M., Makuza, J., Umutesi, J., Nsanzimana, S. and Gupta, N., 2017. Controlling hepatitis C in Rwanda: a framework for a national response. Bulletin of the World Health Organization, 96(1), pp.51-58.
[4] Donovan, P., 2002. Rape and HIV/AIDS in Rwanda. The Lancet, 360, pp.s17-s18.
[5] Ourworldunited.shorthandstories.com. 2020. Eliminating Hepatitis C In Rwanda. Available at: https://ourworldunited.shorthandstories.com/Eliminate_HepatitisC_Rwanda/index.html
[6] The Republic of Rwanda, 2012. Rwanda Vision 2020. [online] Kigali: The Republic of Rwanda. Available at: http://www.minecofin.gov.rw/fileadmin/templates/documents/NDPR/Vision_2020_.pdf
[7] Emery, N., 2013. Rwanda’s Historic Health Recovery: What The U.S. Might Learn. [online] The Atlantic. Available at: https://www.theatlantic.com/ health/archive/2013/02/rwandas-historic-health-recovery-what-the-us-might-learn/273226/
[8] Farmer, P., Nutt, C., Wagner, C., Sekabaraga, C., Nuthulaganti, T., Weigel, J., Farmer, D., Habinshuti, A., Mugeni, S., Karasi, J. and Drobac, P., 2013. Reduced premature mortality in Rwanda: lessons from success. BMJ, 346(jan18 1), pp.f65-f65.
[9] Mbituyumuremyi, A., Van Nuil, J., Umuhire, J., Mugabo, J., Mwumvaneza, M., Makuza, J., Umutesi, J., Nsanzimana, S. and Gupta, N., 2017. Controlling hepatitis C in Rwanda: a framework for a national response. Bulletin of the World Health Organization, 96(1), pp.51-58.
[10] Clinton Health Access Initiative. 2020. Partnerships Will Help Rwanda Eliminate Hepatitis C In Five Years - Clinton Health Access Initiative. [online] Available at: https://www.clintonhealthaccess.org/partnerships-will-help-rwanda-eliminate-hepatitis-c-in-five-years/
[11] Makaka, A., Breen, S. and Binagwaho, A., 2012. Universal health coverage in Rwanda: a report of innovations to increase enrolment in communitybased health insurance. The Lancet, 380, p.S7.
[12] Umutesi, G., Shumbusho, F., Kateera, F., Serumondo, J., Kabahizi, J., Musabeyezu, E., Ngwije, A., Gupta, N. and Nsanzimana, S., 2019. Rwanda launches a 5-year national hepatitis C elimination plan: A landmark in sub-Saharan Africa. Journal of Hepatology, 70(6), pp.1043-1045.
[13] Muvunyi, C., Harelimana, J., Sebatunzi, O., Atmaprakash, A., Seruyange, E., Masaisa, F., Manzi, O., Nyundo, M. and Hategekimana, T., 2018. Hepatitis B vaccination coverage among healthcare workers at a tertiary hospital in Rwanda. BMC Research Notes, 11(1).
[14] Mbituyumuremyi, A., Van Nuil, J., Umuhire, J., Mugabo, J., Mwumvaneza, M., Makuza, J., Umutesi, J., Nsanzimana, S. and Gupta, N., 2017. Controlling hepatitis C in Rwanda: a framework for a national response. Bulletin of the World Health Organization, 96(1), pp.51-58.
[15] Ibid
[16] Umutesi, G., Shumbusho, F., Kateera, F., Serumondo, J., Kabahizi, J., Musabeyezu, E., Ngwije, A., Gupta, N. and Nsanzimana, S., 2019. Rwanda launches a 5-year national hepatitis C elimination plan: A landmark in sub-Saharan Africa. Journal of Hepatology, 70(6), pp.1043-1045.
[17] Mbituyumuremyi, A., Van Nuil, J., Umuhire, J., Mugabo, J., Mwumvaneza, M., Makuza, J., Umutesi, J., Nsanzimana, S. and Gupta, N., 2017. Controlling hepatitis C in Rwanda: a framework for a national response. Bulletin of the World Health Organization, 96(1), pp.51-58.
[18] Ibid
[19] Ibid
[20] Clinton Health Access Initiative. 2020. Partnerships Will Help Rwanda Eliminate Hepatitis C In Five Years - Clinton Health Access Initiative. [online] Available at: https://www.clintonhealthaccess.org/partnerships-will-help-rwanda-eliminate-hepatitis-c-in-five-years/
[21] Ibid
[22] Mbituyumuremyi, A., Van Nuil, J., Umuhire, J., Mugabo, J., Mwumvaneza, M., Makuza, J., Umutesi, J., Nsanzimana, S. and Gupta, N., 2017. Controlling hepatitis C in Rwanda: a framework for a national response. Bulletin of the World Health Organization, 96(1), pp.51-58.
[23] Rwanda’s fight in the elimination of Hepatitis C Virus. Kigali: Ministry of Health; 2019. Available from: http://moh.gov.rw/index.php?id=19&tx_news_ pi1[news]=76&tx_news_pi1[day]=1&tx_news_pi1[month]=8&tx_news_pi1[year]=2019&cHash=5bd9a53465e639666f11d1b7aa0ea60a
[24] Clinton Health Access Initiative. 2020. Partnerships Will Help Rwanda Eliminate Hepatitis C In Five Years - Clinton Health Access Initiative. [online] Available at: https://www.clintonhealthaccess.org/partnerships-will-help-rwanda-eliminate-hepatitis-c-in-five-years/
[25] Ourworldunited.shorthandstories.com. 2020. Eliminating Hepatitis C In Rwanda. Available at: https://ourworldunited.shorthandstories.com/ Eliminate_HepatitisC_Rwanda/index.html
Value-based healthcare in Sweden: Reaching the next level
The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.
These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit.
This paper looks at the ways in which Sweden has implemented VBHC, the areas in which it has faced obstacles and the lessons that it can teach other countries and health systems looking to improve the value of their own healthcare investments.
Breast cancer patients and survivors in the Asia-Pacific workforce
With more older women also working, how will the rising trend of breast cancer survivorship manifest in workplace policies, practices and culture? What challenges do breast cancer survivors face when trying to reintegrate into the workforce, or to continue working during treatment? How can governments, companies and society at large play a constructive role?
This series of reports looks at the situation for breast cancer survivors in Australia, New Zealand and South Korea. It finds that while progress has been made, more needs to be done, particularly in South Korea, where public stigma around cancer remains high.Sustaining the push to elimination and beyond: Rwanda’s policy response to hepatitis B and C
Sustaining the push to elimination and beyond: Rwanda’s policy response to hepatitis B and C
For decades, Rwanda has battled significant levels of hepatitis B (HBV) and C (HCV) infections. Sidonie Uwimpuhwe, Rwanda’s Country Director at the Clinton Health Access Initiative (CHAI) reports that an estimated 4% of the population were with living with HCV, whilst HBV prevalence was around 2% when the programme started. The burden is more pronounced in those over the age of 55, where HCV prevalence rises to 16%.1 The scale of infection is also slightly higher in vulnerable populations, such as those living with other conditions like HIV.
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Putting money on the table: Nigeria’s policy response to hepatitis B and C
Nigeria has seen a steady increase in the prevalence of viral hepatitis over the past few decades. The introduction of a routine immunisation programme in 2004 for hepatitis B contributed to a drop in the overall rate of hepatitis infection in children; the number of cases in adults continues to rise.1
The Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) in 2018 estimates that the overall prevalence of hepatitis B (HBV) is 8.1% and 1.1% for hepatitis C (HCV). This means that an estimated 19 million Nigerians are living with HBV or HCV.2
Hepatitis B and C are particularly deadly forms of the virus, as they can cause chronic illnesses leading to liver cirrhosis and cancer. Since HIV, HBV and HCV are all transmitted through blood and other body fluids, people are often “co-infected” with more than one of these infections. Co-infection rates remain a cause for concern, with the NAIIS survey revealing rates of 9.6% and 1.1% for HIV/HBV and HIV/ HCV co-infections respectively in people living with HIV.3
However, Dr Ruth Bello, Consultant Hepatologist in Nasarawa State highlights that the burden in rural and marginalised Nigerian communities has been found to be higher than the national average. She says that over the last three years in Nasarawa State, the prevalence of HBV and HCV was reported to be 10% and 13.2% respectively, Figure 1 summarises the key factors contributing to the transmission of viral hepatitis in Nigeria, across community, healthcare system and government factors.
Low levels of health awareness and poor-health seeking behaviours are key drivers
Both HBV and HCV infections are preventable through the avoidance of risk factors. For HBV, although there is currently no cure, a vaccine is available. Mother-to-child (or vertical) transmission is one of the main routes of infection, accounting for 90-95% of chronic childhood HBV infection that persists into adulthood.4 Despite free HBV vaccination being available via the routine childhood immunisation programme in Nigeria, the uptake remains poor, with vaccine coverage estimated to be around 51%.2 Dr David Uzochukwu, a general practitioner specialising in hepatitis diagnosis and treatment, attributes this partly to poor health knowledge with individuals against vaccination as a practice. Dr Danjuma Adda, Founder of Chagro Care Trust and patient advocate agrees, explaining that the poor uptake rate is especially noticeable in more rural and socio-economically deprived areas, where culture and religion have a strong influence, and individuals often seek medical advice from alternative medical practitioners and herbalists.
Apart from vaccination, screening is vital to find how many people in the country are living with either an HBV or HCV infection, and to link them to the right care. On World Hepatitis Day 2020, the World Hepatitis Alliance chose the theme “find the missing millions” to highlight those people who remain undiagnosed and therefore untreated. The nature of the infections means that HBV and HCV are usually asymptomatic and can go unnoticed until individuals’ livers are significantly damaged. Often described as Nigeria’s silent killer, figures show that more than half the population is likely to have never been tested.8 Poor health-seeking behaviours are a major challenge that makes screening for viral hepatitis difficult in Nigeria. Similarly, most Nigerians do not attend annual medical checks where there is the opportunity for infections to be detected early. In parts of northern Nigeria where there are areas dealing with conflict, this further impacts the success of advocacy, screening and immunisation programmes.5 Organisations such as the Society of Family Health (SFH) in Nigeria recognise the importance of bringing health closer to individuals and their homes to improve access to, and uptake of, essential health information and services. For example, SFH supports the Nigerian government with service delivery by utilising primary health care facilities and social franchising networks comprising private and faith-based hospitals.6
“Decentralisation of care and taskshifting to non-specialists is one way in which the management of hepatitis could be rapidly improved in Nigeria.” Dr Ruth Bello
Furthermore, gaps in knowledge around infection prevention and control, and safe needle exchange among health professionals needs to be addressed across the country. At present, the majority of hepatitis expertise is concentrated within highly specialised health facilities (tertiary care).2 Dr Uzochukwu concurs, outlining that in 2016, there were approximately 108 hepatitis specialists in Nigeria, all of whom were practicing in the major cities. This shortage of experts and the resulting geographic barrier to access is problematic, as many general practitioners working in primary care are not well trained in how to diagnose HBV or HCV, which laboratory tests are required and which treatments to administer. There is also lack of awareness on modes of transmission among health workers, with a study finding that only 44% of health workers were aware that HBV could pass between mother and child.7 All healthcare workers should receive ongoing training and education on the routes of hepatitis transmission and diagnosis and treatment options.8
Awareness about the disease is also low because the Nigerian government has not placed enough focus on partnering with non-governmental organisations and donor agencies that concentrate solely on advocating for hepatitis elimination. Traditionally, the focus has been on treating diseases such as HIV and TB, which has left the hepatitis programme in the country underfunded.9 With undiagnosed hepatitis being such a critical problem in Nigeria, it is imperative that more initiatives and campaigns to raise awareness on viral hepatitis are launched.
Addressing funding issues surrounding hepatitis screening, diagnosis and treatment
Besides improving levels of knowledge on viral hepatitis in Nigeria, the gaps in funding for screening, diagnosis and treatment are probably the most critical issues to address.
Dr Uzochukwu says that with the help of civil society organisations, donors and advocates, free screening camps for HBV and HCV have been made available in some parts of the country. However, these are not geographically accessible by everyone who needs them, and the Nigerian Government is yet to fund the camps on a large-scale basis. Moreover, even though some free hepatitis screening programmes are available for pregnant women, there is no funding available to provide vaccinations and prevent infection in those mothers who test negative. In the same way, there are no affordable HBV vaccination schemes in place for at-risk populations including healthcare workers, people who inject drugs and men who have sex with men.2 Nevertheless, the national hepatitis clinical guidelines recommend that at-risk populations such as healthcare professionals and key workers be screened for hepatitis infection.4
Despite a significant push to implement universal health coverage in Nigeria, approximately 95% of the population is still not covered by the National Health Insurance Scheme.2, 8 In addition to this, the 2016 National Guidelines for the Prevention, Care and Treatment of Viral Hepatitis focus on the inclusion of viral hepatitis as part of the universal health coverage, however, this is yet to happen.4 Since the cost of vaccines, testing and treatment must be paid for privately, this significantly hampers uptake. Dr Danjuma Adda comments that with 55% of Nigerians living on less than 1 USD a day, hepatitis screening, diagnosis and treatment is beyond the reach of most citizens. He estimates that of the 19 million individuals predicted to be living with viral hepatitis, less than 5% can afford to be tested. This is not too surprising, given that a viral load test for hepatitis costs 20,000 Naira (53 USD) and the 12-week treatment course for curing a chronic HCV infection costs between approximately 200 to 300 USD.9 Moreover, Dr. Adda says that a significant amount of the rapid test kits being used in primary and secondary care are not prequalified by the World Health Organization, making them unreliable. The better-quality testing equipment such as enzyme-linked immunosorbent assay (ELISA) and molecular platforms for viral load, are generally only available in tertiary care settings. To add to the problem, these are often in limited supply. According to Dr Adda and Dr Uzochukwu, the substantial accessibility issues force individuals to turn to herbalists for alternative treatments, which often worsens their condition.
Over the years, the Nigerian government along with Society for Gastroenterology and Hepatology has been partnering with donor organisations to come up with ways to make hepatitis care more affordable and accessible in the country, but more financing is required.8
Nasarawa State takes matters into its own hands
As a whole, the country has been slow to fully implement its strategies, which has spurred responses at the State level to scale testing and treatment. Nasarawa is leading in these efforts and serves as a valuable case study. In 2015, the State government launched their initial viral hepatitis elimination program and in February 2020, announced its 5-year HCV elimination plan. The plan aims to screen over 2.4 million individuals and treat 124,000 by 2024, six years ahead of the WHO’s 2030 target.10
Dr Ruth Bello, who is a member of the Viral Hepatitis Technical Working Group in Nasarawa, says that the State government has improved hepatitis services by shifting tasks where possible. Task-shifting and strengthening of hospital and specialist health services across the state has stimulated increased awareness and demand for viral hepatitis services. Despite the effect of the covid-19 pandemic on the resilience of the Nigerian health system, the Nasarawa State government has proceeded to build the capacity of healthcare workers across 21 health facilities to improve hepatitis care. Through the commitment of a seed fund of 40 million Naira (110, 000 USD), Nasarawa has screened over 85,000 people and cured 1,300 of those who were found to be infected.9
Looking forward to 2030 and the need for more commitment
With 2030 coming up fast and considering the impact of the covid-19 pandemic on health systems around the globe, Nigeria will need to quickly gain momentum on its efforts towards elimination of viral hepatitis if it is to going to reach the WHO target. The country has what it takes to achieve this goal in terms of the plans, strategies and guidelines that it already has in place. However, further political and financial commitment by the Nigerian government is needed to implement these policies.
Looking ahead, the Ministry of Health should prioritise partnerships with donor organisations to fund the expansion of the National Health Insurance Scheme to cover all aspects of hepatitis care. National-level price negotiations for viral hepatitis testing and treatments could further support this expansion of access. Hepatitis awareness campaigns for the general public and healthcare professionals are also important to increase health literacy and improve health-seeking behaviour. Additionally, healthcare professionals require training to raise awareness of and knowledge about viral hepatitis. Central government could also seek to learn from best practice examples within the country to improve services.
While every effort has been taken to verify the accuracy of this information, The Economist Intelligence Unit Ltd. cannot accept any responsibility or liability for reliance by any person on this report or any of the information, opinions or conclusions set out in this report. The findings and views expressed in the report do not necessarily reflect the views of the sponsor.
[1] Nwokediuko S. Chronic Hepatitis B: Management Challenges in Resource-Poor Countries. Hepatitis Monthly [Internet]. 2011;11(10):786-793. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3234575/
[2] The Journey to Hepatitis Elimination in Nigeria - Hepatitis B Foundation [Internet]. Hepatitis B Foundation. 2020 Available from: https://www.hepb.org/blog/journey-hepatitis-elimination-nigeria/
[3] World Hepatitis Day: Nigerians implored to be screened and vaccinated - Nigeria [Internet]. WHO. 2019 Available from: https://www.afro.who.int/news/world-hepatitis-day-nigerians-implored-be-screened-and-vaccinated?country=979&name=Nigeria
[4] Why Nigeria must find everyone who has hepatitis and doesn’t know it [Internet]. The Conversation. 2020. Available from: https://theconversation.com/why-nigeria-must-find-everyone-who-has-hepatitis-and-doesnt-know-it-143208
[5] Dying Unaware: Race to rescue “the missing millions” from hepatitis in Nigeria [Internet]. Nigeria Health Watch. 2019. Available from: https:// nigeriahealthwatch.medium.com/dying-unaware-race-to-rescue-the-missing-millions-from-hepatitis-in-nigeria-98b80b07b1be
[6] Health and Social Systems Strengthening. Society for Family Health, Nigeria. 2020. Available from: https://www.sfhnigeria.org/health-and-socialsystems-strengthening/
[7] Kolawole, Akande & Akere, Adegboyega & Osundina, Morenike. (2018). Knowledge of hepatitis B virus and vaccination uptake among hospital workers in south west, Nigeria.
[8] Enabulele O. Achieving Universal Health Coverage in Nigeria: Moving Beyond Annual Celebrations to Concrete Address of the Challenges. World Medical & Health Policy. 2020;12(1):47-59.
[9] Folorunsho-Francis A. At N20,000, hepatitis test is beyond most Nigerians -Investigation - Healthwise [Internet]. Healthwise. 2020. Available from: https://healthwise.punchng.com/at-n20000-hepatitis-test-is-beyond-most-nigerians-investigation/
[10] Nasarawa Budgets N40m To Combat Hepatitis. Hepatitis Voices. 2020 Available from: https://hepvoices.org/2020/02/nasarawa-budgets-n40m-tocombat-hepatitis/
Value-based healthcare in Sweden: Reaching the next level
The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.
These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit.
This paper looks at the ways in which Sweden has implemented VBHC, the areas in which it has faced obstacles and the lessons that it can teach other countries and health systems looking to improve the value of their own healthcare investments.
Breast cancer patients and survivors in the Asia-Pacific workforce
With more older women also working, how will the rising trend of breast cancer survivorship manifest in workplace policies, practices and culture? What challenges do breast cancer survivors face when trying to reintegrate into the workforce, or to continue working during treatment? How can governments, companies and society at large play a constructive role?
This series of reports looks at the situation for breast cancer survivors in Australia, New Zealand and South Korea. It finds that while progress has been made, more needs to be done, particularly in South Korea, where public stigma around cancer remains high.Endgame: Egypt’s path to eliminating hepatitis B and C
Endgame: Egypt’s path to eliminating hepatitis B and C
The scale of infection with the hepatitis C virus (HCV) in Egypt was unlike any other country in the world—in 2015 an estimated 6.3% of the population was living with the virus. With a population of 93m at the time, that amounted to close to 6m people. In comparison, the prevalence of hepatitis B virus (HBV) was much lower, estimated at 1% of the total population.
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Taking aim: The policy response to viral hepatitis in Uganda
“What you don’t know can’t hurt you” doesn’t apply to Uganda’s health challenges with hepatitis B and C. Data on prevalence are sparse, particularly for the hepatitis C virus (HCV). Based on small-scale studies, prevalence of HCV is estimated at 1-2% of the total population, says Ponsiano Ocama, chair of the department of medicine and academic hepatologist at Makerere University College of Health Sciences. Estimates for the hepatitis B virus (HBV) are better but based on an HIV impact assessment survey conducted in 2016. It places prevalence at 4.3% of the population aged between 15 and 49 years, with the highest prevalence in the northern region of the country.
There is evidence, albeit limited, that viral hepatitis is a growing health challenge in Uganda. Screening of blood donations for HBV and HCV has thus far been the primary source for identifying infections. According to a government-issued press release, Uganda Blood Transfusion Services has reported an increase in HBV found in blood donations from 1.9% in fiscal year 2012/13 (July-June) to 2.3% in 2016/17, confirming the higher prevalence in the northern and eastern parts. In addition, researchers have recently discovered three new strains of HCV in Uganda.
Importantly though, these figures exclude prevalence in children. In Uganda, HBV is mainly acquired before the age of five, explains Dr Ocama, believed to largely be the result of mother-to-child transmission. Among adults, modes of transmission are thought to include pre-used needles or shared blades, arising from skin scarification practices prevalent in some parts of the country.
At the Uganda Cancer Institute, the largest public-sector cancer institute in East Africa, “out of 280 liver cancer patients in 2018, 80-90% were attributable to viral hepatitis”.
Dr Olaro Charles, director curative services, Ministry of Health, Uganda
The health and financial burden of hepatitis B and C on patients and the government can be high, but with no robust estimates of the economic burden, the severity in Uganda is difficult to assess. One outcome that experts we interviewed emphasise is that chronic hepatitis can progress to liver cancer. At the Uganda Cancer Institute, the largest public sector cancer institute in East Africa, “out of 280 liver cancer patients in 2018, 80-90% were attributable to viral hepatitis,” explains Dr Olaro Charles, director curative services at the Ministry of Health. Addressing chronic hepatitis, he argues, is a way to address the cancer challenge too. Policymakers should assess the short-term costs to test and treat viral hepatitis against the future savings in healthcare expenditure if fewer people require cancer care.
In 2014 the government acknowledged that hepatitis is a serious health concern, making a public declaration to address it. The policies, however, focus almost exclusively on HBV with little or no mention of HCV. In this article, we examine the state of the policy response and priority areas for the future, as Uganda aims to meet this health challenge.
US$3m Amount earmarked in the annual government budget to tackle HBV in Uganda.
Closing the information gap: Reporting and public awareness
An estimated US$3m of the annual government budget has been earmarked to tackle HBV in Uganda. In 2015 they launched a screening and treatment programme exclusively for HBV, targeting those above the age of 15. Those who test negative are given vaccinations, as a preventative measure. This effort started in the north, where the prevalence is very high, followed by east Uganda, with the aim of covering the whole country.
Information gathered as part of the programme will be valuable, providing more data on the prevalence of HBV than what is currently available. This will be important for completing the government’s strategic plan to tackle hepatitis, which is currently under development, and measuring progress in subsequent years. To strengthen its reporting system, in early 2019 the Ugandan government was given access to the Global Hepatitis Reporting System, which was created by the World Health Organisation (WHO). As part of this, various stakeholders in the healthcare system received two days of training by the WHO. Lessons on best practice learned over the course of the African Hepatitis Summit in Kampala in June 2019 may inform the strategy as well.
“Some people think that hepatitis is transmitted like the Ebola virus. So, whenever someone is identified in the community as having hepatitis, the whole community may exclude this person, even in families.”
Kenneth Kabagambe, executive director, National Organisation for People Living with Hepatitis B
In the absence of a formal framework, nongovernmental organisations (NGOs) such as the National Organisation for People Living with Hepatitis B (NOPLHB) have been very active in Uganda. They advocate for the rights of hepatitis patients and improving diagnostic and clinical services for patients. Importantly, they help to raise public awareness about HBV prevention, care and support services.
Resistance to testing for hepatitis stems from stigma and misinformation. Kenneth Kabagambe, the executive director of NOPLHB, says, “Some people think that hepatitis is transmitted like the Ebola virus. So, whenever someone is identified in the community as having hepatitis, the whole community may exclude this person, even in families.” A wider public awareness programme can help to correct misinformation, strengthen prevention practices and encourage people to get tested and treated. Adopting a multi-channel approach—through television, radio and billboards—could help reach the masses.
The building blocks to prevent, test and treat
Experts we interviewed point to health worker training as a priority going forward. Health workers have received training as part of the government’s wider efforts to improve injection safety, but more specific training on viral hepatitis is needed. “At the moment, we still have some health workers who don’t understand what hepatitis B and C is,” states Mr Kabagame. Dr Ocama concurs, explaining that there are challenges with the quality of training programmes. These need to be structured around an approved curriculum, enabling health workers to better identify at-risk patients and effectively treat those infected. To this end, the government is developing treatment guidelines. Broader protections include policies announced in 2014 requiring all health workers to be vaccinated for hepatitis B.
“We are now trying to see the feasibility of having HBV services integrated to the HIV setting. And then, if it is feasible, we are trying to assess what kind of additional funding will be required.”
Dr Ponsiano Ocama, chair of the department of medicine and academic hepatologist, Makerere University College of Health Sciences
To tackle the prevalence of HBV among children, the government introduced a vaccination programme for infants at six weeks after birth. Based on one study in Uganda, the programme seems to be effective: among 73 children who had been vaccinated, none were infected with HBV. To strengthen this, Mr Kabagambe advocates for the “birth dose”, under which infants receive the first dose within 24 hours after birth, in line with WHO recommendations. To safeguard against mother-to-child transmission, hepatitis testing should be made mandatory for pregnant women, asserts Mr Kabagambe.
Another gap in the system in Uganda is the completion rate of the vaccination programme among those who test negative. At present, 92% of those eligible for the hepatitis B vaccine receive the first dose, 68% receive the second dose and only 33% receive the third dose. Educating patients on the importance of vaccinations and completing treatment is part of the solution, and should be a core pillar of the country’s strategy for preventing and reducing transmission. Another part of the solution will be driving operational efficiency, making these subsequent doses more accessible to patients living in remote areas in particular.
The finance function
Across the system, improving access to testing and treatment has two components, both rooted in financial constraints. The first is that patients are required to pay for some tests before starting treatment. This is resulting in delayed diagnosis, explains Mr Kabagambe: “We are seeing that most of the patients who are infected are going to hospitals when they are at the end stage of the disease, when it is very advanced.”
The second impediment to testing and treating is that diagnostic equipment, especially in rural areas, is often made available through donor funds, which do not take into consideration maintenance and other recurrent costs.
To tackle the financing challenge, opportunities to integrate hepatitis services with HIV programmes could be leveraged. There are many similarities between HIV and hepatitis in terms of transmission, disease progression, diagnostic and monitoring equipment required, and in some cases the treatment too. Globally, between 5% and 20% of people living with HIV are also infected with HBV. “We are now trying to see the feasibility of having HBV services integrated to the HIV setting,” says Dr Ocama. “And then, if it is feasible, we are trying to assess what kind of additional funding will be required.”
The Global Fund to Fight AIDS, TB and Malaria now allows applicants to include work to address HIV comorbidities such as hepatitis in their funding requests. However, such requests would need to come from the country’s allocated funding for HIV, which already falls short of what is required in the case of Uganda. That may explain why funding for hepatitis has so far relied entirely on domestic sources, but this does not preclude opportunities for funding integration in the future.
Looking ahead
The Ministry of Health is taking some positive steps to address hepatitis in Uganda, with a dedicated budget and staff as well as the development of a strategic plan. But the plan must take into consideration various facets of the health issue.
Enhancing reporting from the screening programme under way as well as a planned nationwide survey will provide much-needed data on HBV and HCV prevalence. This will enable the government to craft evidence-based policies and plans with specific targets. Without plans and targets, it will be difficult to assess progress and the degree of alignment with WHO recommendations.
Emphasis on health worker training and providing treatment guidelines will be critical for the successful implementation of the strategy. In addition, the government can leverage the expertise of active NGOs in the country and build on their efforts to raise public awareness and advocate for patients’ rights and services. Broader education efforts to erase the stigma attached to these curable and preventable diseases will be an important driver of success as Uganda works towards the WHO goal of eliminating hepatitis B and C by 2030.
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The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.
These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit.
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This series of reports looks at the situation for breast cancer survivors in Australia, New Zealand and South Korea. It finds that while progress has been made, more needs to be done, particularly in South Korea, where public stigma around cancer remains high.Taking aim: The policy response to viral hepatitis in Uganda
Taking aim: The policy response to viral hepatitis in Uganda
“What you don’t know can’t hurt you” doesn’t apply to Uganda’s health challenges with hepatitis B and C. Data on prevalence are sparse, particularly for the hepatitis C virus (HCV). Based on small-scale studies, prevalence of HCV is estimated at 1-2% of the total population, says Ponsiano Ocama, chair of the department of medicine and academic hepatologist at Makerere University College of Health Sciences. Estimates for the hepatitis B virus (HBV) are better but based on an HIV impact assessment survey conducted in 2016.
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Endgame: Egypt’s path to eliminating hepatitis B and C
The scale of infection with the hepatitis C virus (HCV) in Egypt was unlike any other country in the world—in 2015 an estimated 6.3% of the population was living with the virus. With a population of 93m at the time, that amounted to close to 6m people. In comparison, the prevalence of hepatitis B virus (HBV) was much lower, estimated at 1% of the total population.
The high prevalence of HCV in Egypt can be traced back to a programme that ran between the 1950s and 1980s to combat schistosomiasis, a water-borne parasitic disease that was endemic in the Nile Delta. Executed by the Egyptian Ministry of Health and Population with the advice and support of the World Health Organisation (WHO), 36m injections were administered to more than 6m people. Undertaken almost entirely with unsterilised and pre-used syringes and needles, the programme inadvertently transmitted HCV, which was not well known at the time. This, combined with weak infection control measures (such as quality controls for blood donations), led to high transmission rates and high prevalence.
Despite high HCV prevalence, the HBV-HCV co-infection rate was found to be just 0.06%, and the geographical distribution of the two infections differed markedly. Exposure to household members who are HBV positive has been found to be the main mode of transmission.
US$3.82bn Estimated economic burden of HCV in Egypt in 2015
The impact of HCV and HBV can be assessed on two fronts: the personal effects of the disease and its impact on economies in terms of employee productivity and direct medical costs. Chronic hepatitis is detrimental to a person’s quality of life, as they can experience fatigue and depression. There is a risk of developing progressive liver damage, which can lead to liver cancer or failure. HCV can increase the risk of type 2 diabetes and other health issues too. Both adversely impact employee productivity through disability and mortality. Specifically for HCV in Egypt, the economic burden was estimated at US$3.82bn in 2015. In terms of direct costs, HCV testing and treatment amounted to some 4% of total health expenditure in 2015 (over US$700m). The same study shows that treating over 300,000 individuals with HCV each year with antivirals could reduce its prevalence by 94% and liver-related deaths by 75% by 2030. Under this scenario, direct costs would be incurred, especially in the short-term to test and treat. But when indirect costs are taken into account, the intervention can be cost saving. Between 2015 and 2030, the estimated savings stand at US$4.6bn for direct costs and US$26.9bn for indirect costs.
Given the scale of the health issue, the response from the Egyptian government has been to craft and implement a national screening programme for chronic hepatitis, focusing on HCV, as well as treating those infected. The programme reached a milestone in May 2019, having screened 50m people across the country in six months. These efforts have been supplemented with infection prevention and control, ongoing surveillance and continued public education to sustain the positive health impact. As many countries in Africa and beyond battle against hepatitis B and C, there are vital lessons to learn from Egypt’s experience.
Reaching millions
As part of the Egyptian government’s commitment to address this health issue, they formed the National Committee for Control of Viral Hepatitis (NCCVH) in 2006, comprising representatives from the Ministry of Health and Population as well as liver and viral hepatitis experts.
The initial challenge was the state of public awareness. Three national studies had concluded that there were serious knowledge gaps in people’s understanding of hepatitis C. The response was to roll out a multi-channel mass education campaign, with clear messages for the public on risk factors (for those who have had surgery, blood transfusions or schistosomiasis injections), transmission modes (including reused syringes and shaving razors) and registering for testing.
In addition to other government initiatives to reach those in rural areas, Gamal Shiha, chairman of the board of trustees at the Egyptian Liver Research Institute and Hospital, and his colleagues at Mansoura University, launched the “Educate, Test and Treat” programme. Implemented across 73 villages, it was designed to educate people about viral hepatitis and start treatment rapidly. Education needs to be the first step, advises Dr Shiha. “If you go to a village without talking to the people and say ‘please come and be tested’, 50% will not come. But after we provide some information, people in the villages were welcoming.”
“When you cure everybody, there will be no transmission. We consider the massive treatment programme one of the pillars of prevention in addition to infection control.”
Dr Imam Waked, professor of hepatology, National Liver Institute
“We spent a lot on the media campaign but it was important to encourage people to come for testing,” says Wahid Doss, chairman of the NCCVH. The ambitious screening programme called “100 million healthy lives” cost between US$250m and US$300m and was partly funded from a loan by the World Bank. Of the 5m people estimated to have been living with HCV in 2014, 2.5m were treated between 2014 and early 2019, and 1.8m are expected to be treated by the end of 2019. As a result, the prevalence of HCV in Egypt is expected to decline from 7% to less than 1%. “When you cure everybody, there will be no transmission,” explains Imam Waked, professor of hepatology at the National Liver Institute at the University of Menoufiya and a member of the NCCVH. “We consider the massive treatment programme one of the pillars of prevention in addition to infection control.”
The 2-3% treatment failures would translate to about 50,000 patients who will need more specialised treatment that is not readily available in Egypt.
The last mile
At each stage from initial screening, there is a risk of drop-off as people fail to come back for further tests or complete treatment. The problem is most acute in rural areas, given long distances from testing and treatment centres and high levels of poverty. Layer this with cultural impediments (particularly among women, who are reluctant to leave behind their obligations at home to travel large distances) and it is easy to see why drop-off-rates can be high. To reduce the number of visits required, the “Educate, Test and Treat” programme led by Dr Shiha found a way to offer all the tests required to initiate treatment on a single day.
Going forward, a key challenge will be dealing with treatment failures. Even in the best scenarios, cure rates are between 97-98%. The 2-3% treatment failures would translate to about 50,000 patients who will need more specialised treatment that is not readily available in Egypt. To protect against transmissions from treatment failures, adoption of infection prevention and control measures can be effective.
A holistic approach
To eliminate HCV as a public health threat by 2023 requires a well-rounded approach beyond the current mass-screening and treatment campaign. These include a range of infection prevention and control policies, funded through a combination of government resources and a loan from the World Bank given to upgrade Egypt’s health system, explains Dr Waked.
To incentivise patients to report on treatment outcomes, the Ministry of Health and Population offered a certificate of cure, which was required to secure employment abroad. This improved reporting rates dramatically to 67%, from 25%
Injection safety, which addresses an important mode of transmission for viral hepatitis, has improved over the years. A recent assessment by the WHO found that all public-sector hospitals and 98% of private-sector hospitals used needles and syringes taken from a sterile packet or fitted with caps. To enhance this, healthcare facilities across Egypt will be required to use only auto-disabled syringes by July 2020. Greater adoption of best practice around preparing injections in a dedicated area and cleaning of needles are required.
To further strengthen infection prevention and control, blood banks will be conducting more stringent analysis of blood donations. In addition, the WHO’s national standards for blood transfusion services are being disseminated across Egypt to ensure that protocols for safe transfusion of blood are followed, complemented by efforts to improve regulatory oversight. This entails the formation of a national blood authority and revising the blood safety law.
Prevention measures for HBV have been in place for decades. Egypt began vaccinating infants in 1992, although testing of pregnant women has not been consistent. One study concludes that the existing vaccination programme provides adequate protection. From early 2019, hospitals have been administering the “birth dose”, delivering the first dose of the vaccine within 24 hours after birth (previously the first dose was given two months after birth). As part of the screening and treatment programme for HCV, vaccinations for HBV were also provided.
For further analysis of progress on eliminating HBV and HCV, the government needs to close the reporting gap. To incentivise patients to report on treatment outcomes, the Ministry of Health and Population offered a certificate of cure, which was required to secure employment abroad. This improved reporting rates dramatically to 67%, from 25%; follow-ups over the phone pushed the rate higher, to 75%. Experts we interviewed suggest that all public and private facilities should be reporting into the same database, with a clear link to individual patient IDs.
Sustaining the positive health impact
Looking ahead, health workers and people themselves must remain vigilant for symptoms of viral hepatitis and risk factors for transmission. But the government in Egypt must continue to provide the tools necessary, including frequent training for health workers as conditions evolve and an extended public education programme.
The screening programme accelerated the efforts to reach the millions who were infected, justified by the scale of the health issue. “It required estimating the magnitude of the problem, establishing treatment centres around the country and securing the political will and financing to provide affordable treatment to the people,” describes Dr Doss. But this must be complemented with effective infection prevention and control policies, including injection and blood safety, to reduce transmission. Dr Shiha concludes, “The government’s direction is very good and the commitment makes me happy. My dream is an Egypt, and a whole world, free of hepatitis C and B.”
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The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.
These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit.
This paper looks at the ways in which Sweden has implemented VBHC, the areas in which it has faced obstacles and the lessons that it can teach other countries and health systems looking to improve the value of their own healthcare investments.
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With more older women also working, how will the rising trend of breast cancer survivorship manifest in workplace policies, practices and culture? What challenges do breast cancer survivors face when trying to reintegrate into the workforce, or to continue working during treatment? How can governments, companies and society at large play a constructive role?
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The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.
These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit.
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This series of reports looks at the situation for breast cancer survivors in Australia, New Zealand and South Korea. It finds that while progress has been made, more needs to be done, particularly in South Korea, where public stigma around cancer remains high.
The Cost of Silence
Cardiovascular diseases levy a substantial financial toll on individuals, their households and the public finances. These include the costs of hospital treatment, long-term disease management and recurring incidence of heart attacks and stroke. They also include the costs of functional impairment and knock-on costs as families may lose breadwinners or have to withdraw other family members from the workforce to care for a CVD patient. Governments also lose tax revenue due to early retirement and mortality, and can be forced to reallocate public finances from other budgets to maintain an accessible healthcare system in the face of rising costs.
As such, there is a need for more awareness of the ways in which people should actively work to reduce their CVD risk. There is also a need for more primary and secondary preventative support from health agencies, policymakers and nongovernmental groups.
To inform the decisions and strategies of these stakeholders, The Economist Intelligence Unit and EIU Healthcare, its healthcare subsidiary, have conducted a study of the prevalence and costs of the top four modifiable risk factors that contribute to CVDs across the Asian markets of China, Australia, Hong Kong, Japan, Singapore, South Korea, Taiwan and Thailand.
Download the report to learn more.
Policy Approaches to Tackling Hepatitis C in Spain
Policy Approaches to Tackling Hepatitis C in Spain
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Regional administrations have treated almost twice as many people as initially expected. Yet much work remains to be done before Spain can achieve its goal of eliminating the disease. Even as the per patient cost of administering new direct-acting antiviral (DAA) drugs falls, the country may have to commit further resources to detecting potentially thousands of as-yet unidentified Hepatitis C virus (HCV) patients.
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These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit.
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To inform the decisions and strategies of these stakeholders, The Economist Intelligence Unit and EIU Healthcare, its healthcare subsidiary, have conducted a study of the prevalence and costs of the top four modifiable risk factors that contribute to CVDs across the Asian markets of China, Australia, Hong Kong, Japan, Singapore, South Korea, Taiwan and Thailand.
Download the report to learn more.
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The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.
These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit.
This paper looks at the ways in which Sweden has implemented VBHC, the areas in which it has faced obstacles and the lessons that it can teach other countries and health systems looking to improve the value of their own healthcare investments.
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With more older women also working, how will the rising trend of breast cancer survivorship manifest in workplace policies, practices and culture? What challenges do breast cancer survivors face when trying to reintegrate into the workforce, or to continue working during treatment? How can governments, companies and society at large play a constructive role?
This series of reports looks at the situation for breast cancer survivors in Australia, New Zealand and South Korea. It finds that while progress has been made, more needs to be done, particularly in South Korea, where public stigma around cancer remains high. The Cost of Silence
Cardiovascular diseases levy a substantial financial toll on individuals, their households and the public finances. These include the costs of hospital treatment, long-term disease management and recurring incidence of heart attacks and stroke. They also include the costs of functional impairment and knock-on costs as families may lose breadwinners or have to withdraw other family members from the workforce to care for a CVD patient. Governments also lose tax revenue due to early retirement and mortality, and can be forced to reallocate public finances from other budgets to maintain an accessible healthcare system in the face of rising costs.
As such, there is a need for more awareness of the ways in which people should actively work to reduce their CVD risk. There is also a need for more primary and secondary preventative support from health agencies, policymakers and nongovernmental groups.
To inform the decisions and strategies of these stakeholders, The Economist Intelligence Unit and EIU Healthcare, its healthcare subsidiary, have conducted a study of the prevalence and costs of the top four modifiable risk factors that contribute to CVDs across the Asian markets of China, Australia, Hong Kong, Japan, Singapore, South Korea, Taiwan and Thailand.
Download the report to learn more.
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The need to get better value from healthcare investment has never been more important as ageing populations and increasing numbers of people with multiple chronic conditions force governments to make limited financial resources go further.
These pressures, along with a greater focus on patient-centred care, have raised the profile of VBHC, especially in European healthcare systems. Sweden, with its highly comprehensive and egalitarian healthcare system, has been a leader in implementing VBHC from the beginning, a fact that was underscored in a 2016 global assessment of VBHC published by The Economist Intelligence Unit.
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With more older women also working, how will the rising trend of breast cancer survivorship manifest in workplace policies, practices and culture? What challenges do breast cancer survivors face when trying to reintegrate into the workforce, or to continue working during treatment? How can governments, companies and society at large play a constructive role?
This series of reports looks at the situation for breast cancer survivors in Australia, New Zealand and South Korea. It finds that while progress has been made, more needs to be done, particularly in South Korea, where public stigma around cancer remains high. The Cost of Silence
Cardiovascular diseases levy a substantial financial toll on individuals, their households and the public finances. These include the costs of hospital treatment, long-term disease management and recurring incidence of heart attacks and stroke. They also include the costs of functional impairment and knock-on costs as families may lose breadwinners or have to withdraw other family members from the workforce to care for a CVD patient. Governments also lose tax revenue due to early retirement and mortality, and can be forced to reallocate public finances from other budgets to maintain an accessible healthcare system in the face of rising costs.
As such, there is a need for more awareness of the ways in which people should actively work to reduce their CVD risk. There is also a need for more primary and secondary preventative support from health agencies, policymakers and nongovernmental groups.
To inform the decisions and strategies of these stakeholders, The Economist Intelligence Unit and EIU Healthcare, its healthcare subsidiary, have conducted a study of the prevalence and costs of the top four modifiable risk factors that contribute to CVDs across the Asian markets of China, Australia, Hong Kong, Japan, Singapore, South Korea, Taiwan and Thailand.
Download the report to learn more.