Economic Evaluation on Expansion Strategy of Early Detection Coverage in Pregnant Women and thorough Hepatitis B Vaccination in National Action Plan for Viral Hepatitis Control 2020—2024

Hepatitis B virus (HBV) is a public health threat that can be prevented by vaccination in the first 12 months of life. Most chronic HBV infection cases occur due to perinatal infections, atypical early symptoms, and can proceed to decompensated cirrhosis and hepatocellular carcinoma in adulthood through progressive liver destruction. Treatment may delay the sustainability of the disease's course from chronic HBV infection, but vaccination provides lasting protection, including infection threat from other individuals facilitated through risky behaviors. Health and economic consequences of HBV are very high: an estimated 5%—7% of Indonesians in various age groups are infected with HBV and HBV complications fall into the largest group of catastrophic diseases covered by National Health Insurance (Jaminan Kesehatan Nasional).

Sub-directorate of Hepatitis and Gastro Intestinal Tract Infection Diseases (Hepatitis and GITID Sub-directorate) of the Indonesia Ministry of Health, responded to this situation by planning a series of priority activities contained in the National Action Plan for Viral Hepatitis Control 2020-2024 (NAP 2020). Indicator target has been set to achieve coverage for detection of pregnant women and vaccinations to the universal level as well as gradual provision of additional prophylaxis for eligible pregnant women. Questions about effectiveness and cost of the NAP 2020 strategy implementation, impact on the program budget, and economic benefits generated get a large portion of attention to determine the next recommendations.

Supported by World Health Organization, AIDS Research Center of Atma Jaya Catholic University Jakarta collaborated with Hepatitis and GITID Sub-directorate to conduct an economic evaluation study from the NAP 2020 strategy implementation. The work began from 26-October-2020 and was completed as of 10-December-2020, with various discussions including with the Expert Committee consisting of hepatologists and health economists. This report presents the results of the study.

The study design is a cost-effectiveness analysis that is reviewed from the perspective of public health system. Using Markov modeling method with health conditions that reflect the course of HBV disease, the study projected number of cases, effectiveness, and cost of vaccination and other health programs related to HBV resulting from the cohort born in the period 2020-2024 until the age of 50 years. The study compared two main strategies, that is the status quo (Baseline) strategy, with the current cost and scope of the program, and the NAP 2020 strategy, with increased outreach and promotion intensity to maximize program coverage by up to 100% for pregnant women screening, 95% for vaccination, and 20% for prophylaxis during pregnancy. Epidemiological parameters and costs are summarized from relevant publications. A reduction in disability-adjusted life years (DALY), or a one-year portion affected by pain or death due to HBV, is used as a measure of effectiveness. Fee is stated in rupiah in 2019. A discount rate of 5% per year is used to estimate the amount of effectiveness and costs that occur in the future in current value.

The coverage of the NAP 2020 strategy reached 24.5 million pregnancies that received hepatitis B screening (out of 26.1 million) and 21.1 million children were vaccinated (out of 22.3 million births with screening). Coverage levels for the Baseline strategy reached 12.8 million screened pregnancies and 9.9 million vaccinated children of the same population. Cumulative projections of HBV infections for the period 2020-2070 reach approximately 500,000 cases (60% deaths, 14% hepatocellular carcinoma, 13% decompensated cirrhosis, and 13% chronic infection) for NAP 2020 strategy and 1,800,000 cases (52% death, 13% hepatocellular carcinoma, 14% decompensated cirrhosis, and 21% chronic infection) for Baseline strategy.

Cost per child includes program components and care and treatment of HBV complications that reached Rp2.4 million and Rp5.1 million for each NAP 2020 and Baseline strategy, resulting in savings of Rp2.6 million per child with the NAP 2020 strategy implementation. The NAP 2020 strategy also resulted in a larger reduction in DALY per child (0.82 units) compared to the Baseline strategy (0.30 units). Additional cost of the NAP 2020 strategy to obtain one extra unit of DALY reduction from the resulting Baseline strategy (difference in cost per unit difference of DALY reduction) is negative, which means the NAP 2020 strategy can save on health costs. This conclusion persists with various values of epidemiological parameters and costs contained in the defined range, including whether or not there is a population impact from the strategy implementation in the form of decreasing prevalence rate of HBV.

The financing needs of the NAP 2020 strategy program reached Rp19.4 trillion (Rp16.6 trillion—Rp22.2 trillion), or almost double the Rp9.8 trillion of financing required by the Baseline strategy (Rp8.4 trillion—Rp11.3 trillion) in the period 2020—2024. Meanwhile, the cost of care and treatment of HBV complications reached Rp38.4 trillion (Rp16.2 trillion—Rp64.0 trillion) and Rp110.8 trillion (Rp63.7 trillion—Rp190.2 trillion) for each NAP 2020 strategy and Baseline strategy. The amount of health cost savings of Rp72.4 trillion (Rp46.1 trillion—Rp135.9 trillion) can be generated from the NAP 2020 strategy implementation.

When paired with program costs as investment capital, NAP 2020 strategy has a return on investment of 3.7 times (2.4 times—7.3 times). For every Rp100,000 invested in NAP 2020 strategy, Rp370,000 will be generated (Rp240,000-Rp730,000) of health cost savings within 50 years that can be reallocated for health priorities or other development areas.

The coronavirus disease of 2019 (COVID-19) pandemic increases the program financing needs that do not reach 5% for spending on personal protection and infection prevention facilities during service delivery in the period of 2020—2024. The study does not attempt to calculate the amount of program coverage changes as an impact of the pandemic that has potential to reduce people's demand for vaccinations and offer of services provided due to turmoil in health system that occurs to prioritize the response to handling COVID-19. This is a key limitation of this study in addition to the limitations of the data used and the focus of program impacts that do not cover populations outside the birth cohort.

In conclusion, the NAP 2020 strategy implementation is an efficient policy choice and has implications for health cost savings. Investment in financing this strategy will generate a positive rate of return and improve the degree of public health in Indonesia. Program managers and policy makers need to pay attention to the following aspects to ensure the success of the NAP 2020 strategy when these policy options are to be taken:

• Budget advocacy to meet the financing needs of the strategy implementation, by utilizing the fiscal space available in central and local government.

• Promotion in the community to increase demand for HBV vaccination.

• Adequate logistics chain readiness from point of acquisition to service delivery to keep vaccines, prophylactic drugs, diagnostic tools, and supporting facilities available in sufficient quantities and maintained efficacy.

• Access equity so that each member of the community gets HBV vaccine services with the same ease for all geographical scopes; and

• More information about the impact of the COVID-19 pandemic on program performance which is obtained through advanced research for planning responses to restore performance to achieve implementation goals.