How to expand not only the number of service sites, but also the range of services? Kyrgyzstan’s experience in scaling up access to viral hepatitis treatment programme

A year and a half ago, Kyrgyzstan launched a programme to provide universal access to hepatitis B vaccination, as well as treatment for hepatitis B and C. Below we describe in detail about the successes, challenges and why the country decided to involve family medicine centres in the provision of viral hepatitis services in our material.

WHAT IS THE PROGRAMME AIMED AT AND WHO DOES IT COVER?

Before 2000, vaccination against hepatitis B was not a part of the vaccination calendar, and therefore Kyrgyz citizens born before 2000 were not vaccinated against hepatitis B. Now the country has launched a national state vaccination campaign: those who have not been vaccinated can receive the vaccine at any family medicine centre. This has become possible thanks to the efforts of the Ministry of Health and the Republican Centre for the Control of Haemocontact Viral Hepatitis and HIV (in Russian – Республиканский центр по контролю за гемоконтактными вирусными гепатитами и вирусом иммунодефицита человека МЗ КР).

Screening for viral hepatitis B and C has also recently become available, and in case of a positive immunoenzyme test, a confirmatory PCR (Polymerase Chain Reaction) test can be taken and treatment provided, either at the same family medicine centres or at the Viral Hepatitis and HIV Control Centres (formerly – AIDS Centres). Moreover, the most effective drugs for the treatment of hepatitis B and C (Entecavir, Tenofovir and Sofosbuvir/Velpatasvir) have recently been procured in accordance with the national protocol, and primary health care facilities are already provided with the necessary reagents and rapid tests, which guarantees the practical implementation of the reform.

WHAT WAS IT LIKE BEFORE?

Before, viral hepatitis diagnosis and treatment services were available only for people living with HIV on the basis of AIDS Centres. And when the introduction of hepatitis B and C treatment for the general population began, it was immediately decided to provide these services at the level of primary medicine. AIDS Centres simply could not cope with the influx of clients and providing services at the primary level makes services more accessible to people living in the regions.

As before, medicines are procured centrally and then distributed to family medicine centres. It allows people to be treated locally and free of charge.

WHO ENSURED SUCH CHANGES?

In order to transform the system of diagnosis and treatment of viral hepatitis, series of Ministry of Health orders were adopted at the end of 2022 and the beginning of 2023.First of all, there was a thorough revision of the relevant guidelines, as well as the definition of criteria and population groups – who need vaccination, testing and treatment.

Aibar Sultangaziev is the head of “Partner Network” Association and an international expert on good governance in the field of public health, intellectual property and access to HIV/TB/HCV treatment with many years of experience in coordinating national programmes for key populations and PLWH in Kyrgyzstan. He participated both in defining the list of documents for launching the new programme and directly in the development of these documents.

WHAT ARE THE DIFFICULTIES AND CHALLENGES FOR THE FUTURE?

“In a year and a half, the effect of the reform is very significant and evident. We are already seeing a number of improvements in access to services involving primary care. But there are also some barriers – which we should overcome as soon as possible,” Mr Aybar believes, pointing to the following processes:

1. Untimely procurement of reagents by family medicine centres and the lack of regulations on payments for hepatitis diagnostics to the budgets of these centres by the Compulsory Health Insurance Fund. Not so long ago, there were cases when late procurement led to interruptions in the availability of reagents for PCR analysis, and people were unable to receive free confirmation of diagnosis for several months. Family medicine centres often solved the problem by referring patients to private laboratories for paid services: this is not a solution as such, as it does not contribute to reducing the economic burden on patients and contradicts the concept of UHC.
2. Another challenge is the lack of family doctors who have specialised in hepatitis treatment. Like local procurement management, this too needs to be improved so that family medicine centres can provide fully qualified medical services.

Free hepatitis treatment has recently been enshrined in law in the country – the Law on the Protection of Citizens’ Health has been adopted, which in 2024 should lead to a revision of the state guarantee programme and thus additional resources for the programme on universal access to hepatitis B vaccination and hepatitis B and C treatment. Without increased and stable funding, the full range of hepatitis-related services cannot be realised.