BACKGROUND:In 2022, South Africa had an estimated hepatitis B prevalence of 4·7-6·0%. In an effort to eliminate viral hepatitis as a public health threat, a targeted (ie, selective) hepatitis B birth-dose vaccination (HepB-BD) policy was introduced in 2023. Under this policy, only infants born to mothers with confirmed hepatitis B positivity are eligible for HepB-BD, which is given in addition to peripartum antiviral prophylaxis (PAP) for mothers from the second or third trimester of pregnancy. This policy differs from the WHO recommendation that all newborns should receive a HepB-BD vaccine (ie, a universal HepB-BD policy). We aimed to assess comparative costs and benefits of this and alternate policies in South Africa. METHODS:A validated model of transmission, disease progression, and mortality was used to simulate the ongoing hepatitis B epidemic in South Africa. We projected outcomes from the current South African policy (ie, selective PAP plus selective HepB-BD), a universal HepB-BD-only policy, and the WHO-endorsed selective PAP plus universal HepB-BD policy. Health and economic impacts were compared with a baseline of no HepB-BD coverage, over a 2025-100 time horizon. Costs were reported in consumer price index-adjusted 2024 ZAR and outcomes discounted at 3% per annum. FINDINGS:The current South African HepB-BD policy required fewer vaccinations per outcome averted, with the number needed to vaccinate per vertically acquired chronic hepatitis B infection averted found to be six (95% uncertainty interval 3-15), compared with 462 (223-1479) under a universal HepB-BD-only policy or 77 (38-240) under a selective PAP plus universal HepB-BD policy. Despite incurring the greatest programmatic costs, a selective PAP plus universal HepB-BD policy averted the greatest disease burden and was modelled to be the most cost-effective option at a willingness-to-pay threshold of 0·5 × per-capita gross domestic product (ZAR 57 281). INTERPRETATION:Our findings support implementation of a universal HepB-BD policy alongside South Africa's current hepatitis B viral transmission elimination efforts. FUNDING:Vaccine Impact Modelling Consortium.
Global health researchers, UN agencies, and donors have become expert at documenting the deterioration of population health during conflict, yet documentation has not stopped that deterioration. Drawing on 15 years of field research in Syria, Lebanon, Gaza, and Jordan, we argue that part of the failure of the global health architecture stems not principally from violations of international humanitarian law, but from its design as a technical enterprise detached from the political economy of power, financing, and governance. In practice, the system was structured to document harm rather than to hold anyone accountable for it. We distinguish humanitarian neutrality, understood as the operational duty to assist all civilians, from technical neutrality, which excludes political accountability in ways that protects institutional relationships and funding. We define a political economy of health approach, identify specific actors capable of changing the system, and acknowledge both the real, although uneven, effects of documentation and the structural constraints, namely sovereignty, donor dependence, and entrenched interests, that any reform should confront. Finally, we propose six concrete shifts to move global health from monitoring harm and misery towards enabling accountability.
