Funding the war on hepatitis – deploying innovative finance mechanisms to eliminate hepatitis C in Europe

"In this blog, co-authors Rob Walton (Cello Health Public Affairs), Jeffrey V Lazarus (CHIP, WHO Collaborating Centre on HIV and Viral Hepatitis at Rigshospitalet, the University of Copenhagen and Editor-in-Chief of Hepatology, Medicine and Policy), Homie A. Razavi (Center for Disease Analysis), Jagpreet Chhatwal (Harvard Medical School), Charles Gore (Hepatitis C Trust), Pierre Van Damme (Vaccine & Infectious Disease Institute – VAXINFECTIO, University of Antwerp), Luís Mendão (GAT –Treatment Activist Group), and Angelos Hatzakis (Athens University Medical School and Hepatitis B & C Public Policy Association), discuss an innovative financing mechanism to eliminate Hepatitis C in Europe."

In 2016 the goal of eliminating hepatitis C was recognised as an integral focus for the public health community across Europe. At that year’s EU Hepatitis C Policy Summit in Brussels more than 100 experts introduced an HCV Elimination Manifesto.  Shortly afterwards, the World Health Organization approved its first global hepatitis strategy.

The high price of these treatments could pose a significant financial challenge to healthcare systems. But the costs of failing to take action could potentially be even higher.

It is no coincidence that the emerging international consensus to tackle HCV has come at the same time as the arrival of new and highly effective range of direct-acting antiviral (DAA) treatments for hepatitis C virus (HCV). These new drugs offer, for the first time, a realistic opportunity for the elimination of the disease across Europe by 2030. While effective, the high price of these treatments could pose a significant financial challenge to healthcare systems. But the costs of failing to take action could potentially be even higher. If HCV is left untreated, in many cases it can lead to liver failure and liver cancer which means that a liver transplant is the only viable course of treatment available.

It is clear that, in securing the considerable budget required to eliminate HCV, it is time to look beyond the cash-strapped health sector and consider options from the array of financing tools that have been developed to procure other types of public goods and services.

Current levels of funding and provision of treatment fall well short of those required.

The United Nations has committed to taking urgent action to address the HCV pandemic. New treatments for HCV have the potential to be cost-saving in the long-term, provided that a sizeable and immediate investment is made in diagnosis and treatment. However, current levels of funding and provision of treatment fall well short of those required.

A 2015 report from the European Liver Patients’ Association (ELPA) found that: ‘a large part of the infected population is unaware of their disease status due to a lack of, or underfunding of, screening programmes. Moreover, treatment rates are low in most countries, implying that only a small share of those diagnosed with the disease are undergoing treatment’.

The practice of issuing public debt through commercial bonds is hardly novel, except where healthcare is concerned. Bonds typically have a constructive purpose and are most commonly used by governments to fund the building of bridges, roads and other infrastructure projects. Bond finance is attractive as it can be used to effectively transfer the risks associated with long-term spending commitments from governments to investors. They are an especially powerful instrument if it can be demonstrated that the spending commitment they fund is not open-ended. Through bond finance, not only can governments release money for public spending, but the maturity period can be adjusted to the timeframe in which the investment produces the desired social benefit.

Health services across Europe must find a way to win the war against hepatitis C despite the acknowledged financial challenges.

In healthcare, we fight battles on more than one critical front and hepatitis C is a clear example. By the first quarter of 2016 there were around 3.6 million HCV infections in the EU, but only 1.2 million were diagnosed, 0.9 million had been treated and 0.5 million cured. Health services across Europe must find a way to win the war against hepatitis C despite the acknowledged financial challenges.

We know that new treatments for HCV have the potential to rescue tens of thousands of people each year from an inexorable march towards liver transplant or death. The treatments will help healthcare providers save lives and save money too. Even with competitive drug procurement and price negotiations, the budget needed to treat all patients will still be high. The consequence of our failure to act now, however, would be to pass the burden on to future generations as they themselves become taxpayers, voters and patients.

At the moment, we have an opportunity to eliminate the disease within 15 years and deliver significant savings for governments through lower HCV transmission rates, reduced need for liver transplants and fewer cases of liver cancer. Instead, despite the recommendations of WHO and other public health experts, clinical specialists, policymakers and payers in many countries have restricted access to new treatments, usually to those with the most severely damaged livers.

Despite the recommendations of WHO and other public health experts, clinical specialists, policymakers and payers in many countries have restricted access to new treatments, usually to those with the most severely damaged livers.

Health services across the continent are under pressure, but we believe that HCV treatment through direct-acting antivirals (DAAs) should be viewed as more than in view of the high burden of chronic HCV that they could avert.

It makes sense to look to the past to identify potential solutions for the future. Over the coming year, the co-authors of this article will be collaborating to explore various options in HCV elimination, including the feasibility of long-term bond financing schemes. We want to explore if it is possible to optimize the impact of a technological innovation, like the HCV cure, through financial engineering.

As recently as five years ago, there was simply not enough data available for us to make this judgement. With an improved understanding of the epidemiology of HCV and the population-level impact of treatment, we can now mitigate risk for potential investors and improve outcomes for both patients and healthcare funders.

European nations have the power to transform the lives of those who need care. They can also set an important precedent for struggling health systems around the world. We have the clinical skills, and now the technology is at hand. But we need the resources to finish the job and the political support to establish innovative funding mechanisms. In HCV there is an unprecedented public health opportunity and we need to act quickly and creatively to secure the future.


Hepatology, Medicine and Policy is now accepting submissions on this and related issues. For more information, visit: www.hmap.biomedcentral.com.

 

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