Packing for INHSU? Bring a health systems perspective!

Last week, just prior to the 7 September opening of the International Symposium on Hepatitis Care in Substance Users (INHSU 2016) in Oslo, Norway, I was honoured to address the Danish Parliament on the topic of global and national hepatitis C policies.

The next speaker to follow me was Dr. Jens Lundgren, director of the Centre for Health and Infectious Disease Research (CHIP), Rigshospitalet, University of Copenhagen. Full disclosure: I am a senior researcher at CHIP, and Jens is my boss. I have often appreciated his common-sense way of slicing through thick layers of scientific discourse to express a problem in its simplest terms.

I was not disappointed last week at Parliament. In addition to sharing insights on interactions between Denmark’s municipal and regional health systems, Jens made a provocative statement. Even if the drugs were immediately available to treat everyone with hepatitis C virus (HCV) in Denmark, he said, the population-level elimination of the disease is not currently feasible.

Longstanding health system problems such as the relationship between hospitals and addiction/harm reduction centers must be overcome if we are to reach more people with chronic hepatitis C, including people who inject drugs (PWID).

Why? Because the Danish health system is not configured to effectively reach everyone with chronic HCV infection. Based in part on his experience as the Principal Investigator of Shared Addiction Care Copenhagen, an innovative project that is developing a decentralized hepatitis C shared care model, Jens is convinced that longstanding health system problems such as the relationship between hospitals and addiction/harm reduction centers must be overcome if we are to reach more people with chronic hepatitis C, including people who inject drugs (PWID).

Although data are limited, it is likely that a large proportion of chronically HCV-infected PWID in Denmark do not even know that they have the disease. The existence of unlimited supplies of direct-acting antiviral regimens at public-sector health clinics throughout Copenhagen and the rest of Denmark would not help these people!

And if Denmark, which has one of the best-resourced health systems in the world, is not prepared to eliminate hepatitis C, then what country is?

We need to ask ourselves what is lacking in the national and sub-national health systems that will be charged with driving forward the elimination of hepatitis C

My point is that we need to ask ourselves what is lacking in the national and sub-national health systems that will be charged with driving forward the elimination of hepatitis C. It is not enough to simply aspire to scale up HCV testing programmes for PWID and other underserved populations, and to aspire to reduce loss to follow-up as people diagnosed with HCV progress through the care cascade.

How do health systems need to fundamentally change in order to prevent problems such as under-diagnosis and retention in care from being so onerous in the first place?

Jens’ comments to Parliament reinforced the importance of this question in my mind ­– just in time for INHSU.

As I make my way through the exciting INHSU programme in Oslo this week, I will be looking for opportunities to raise the question and to learn from other delegates about the nature of health system challenges in relation to hepatitis C elimination efforts worldwide.

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