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How to set the agenda for hepatitis C: a theory-driven policy analysis

Background

Hepatitis C virus (HCV) represents a significant public health burden. When new HCV drugs arrived in 2014, the disease became curable, but the administration remained reluctant to address this public health issue. However, the Swiss parliament recently decided to integrate HCV into the next national HIV programme. This study investigates how HCV came onto the political agenda in Switzerland and which actors and factors were influential in this process.

Methods

The data collection is based on document analysis and semi-structured interviews. The transcripts were coded by deriving the codes from the data in terms of content followed by the application of the multiple streams framework.

Results

Health authorities, unlike experts, did not see the HCV epidemic as a relevant public health threat. Due to cost-related restriction of access to treatment, the potential of the new HCV drugs could not be fully exploited. The administration’s position proved difficult to change, despite evidence to the contrary. For 30 years, authorities set the agenda in health policy regarding HCV, unheeded by politicians. But recently, a policy entrepreneur has for the first time successfully managed to put HCV on the political agenda. After years of education and lobbying, it used the window of opportunity in the form of the new edition of the national HIV programme. The parliamentary decision to include HCV in this programme broke the long-standing primacy of the administration in the field of HCV, which had long prevented a more active handling of the HCV field.

Conclusions

The case of HCV in Switzerland shows that evidence alone is not enough to bring about health policy changes. A policy entrepreneur is needed who overcomes resistance, brings together the three streams—problem, policy and political—and exploits the window of opportunity at the right time. To be successful, the policy entrepreneur must identify the indicators that map the problem, network and convince decision-makers, recognize policy windows and use them—as has been the case with HCV in Switzerland.

The Swiss Hepatitis Strategy as a model for facing future health policy challenges

Driven by the increasing evidence of the public health burden of viral hepatitis and the passivity of the health authorities, the Swiss Hepatitis Strategy (SHS) was launched by private initiative with the vision of eliminating viral hepatitis by 2030. The strategy applied the Governmental Learning Spiral method, an approach designed to overcome political barriers and to enhance innovation in the political context. This participative process, where those who develop are also those who implement, enhances a sense of social belonging among the people involved, which leads to the alignment of different viewpoints as well as to the creation of social networks. In consequence, a broader audience becomes involved; this creates feedback loops that lead to the continuous improvement of the strategy process. Within less than five years the SHS has been able to achieve significant goals within the scope of its vision: the implementation of universal access to Hepatitis C therapies has been enforced; increased attention within the general population has been achieved by using progressively more media coverage about therapies, a patient organisation has been founded and the national health authorities have begun to support the strategy financially. The case of the SHS proves, that a carefully designed political learning process is an efficient and innovative tool in the face of today's health policy challenges such as the Hepatitis C epidemic.

[Gaps in Hepatitis C Care of People Who Use Drugs]

Zusammenfassung. Drogenkonsumierende sind mit einer Prävalenz von 56 % die grösste Hepatitis-C-Risikogruppe in der Schweiz. Ihre ungenügende Versorgungssituation stellt ein ernsthaftes Problem für die öffentliche Gesundheit dar, einerseits durch die Weiterverbreitung des Virus und anderseits durch die Folgeerkrankungen der Infektion mit den entsprechenden Kosten. Es sind neue Ansätze gefragt in der Hepatitis-C-Versorgung bei Drogenkonsumierenden. Eine Suchterkrankung und auch Hepatitis C sind chronische Leiden, die häufig von weiteren chronischen Krankheiten begleitet werden. Sie bedürfen einer integrierten multidisziplinären Versorgung. Mit einer Einbindung der Hepatitis-C-Versorgung in das medizinische Grundversorgungssetting können bislang unerreichte Patientengruppen behandelt werden. Die aktuelle Entwicklung in der HCV-Therapie, weg von anspruchsvollen interferonbasierten Behandlungsschemata und hin zu einfachen Kombinationstherapien, unterstützt die Versorgung dieser Risikogruppe.