Beyond burden: a Quality of Care Index (QCI) assessment of hepatitis B in 204 countries, 1990-2021

• Built a composite HBV Quality of Care Index from GBD 1990–2021 data • Revealed widening cross-country inequality despite modest global gains • Lower QCI at older ages indicates delayed diagnosis and limited advanced care • Projections to 2030–2034 show slow improvement and persistent dispersion • One Health actions proposed to narrow gaps and accelerate HBV elimination Background Hepatitis B virus (HBV) remains a leading cause of cirrhosis and hepatocellular carcinoma. Improving outcomes requires effective health-system performance and equitable delivery of prevention and care. Methods Using Global Burden of Disease 1990-2021 estimates for 204 countries/territories, we derived an HBV Quality of Care Index (QCI) from four secondary ratios (mortality-to-incidence, DALYs-to-prevalence, YLL-to-YLD, prevalence-to-incidence) using principal component analysis and rescaled it to 0-100. We assessed temporal trends, sex- and age-specific patterns, Socio-demographic Index (SDI) gradients, and inequality (slope and concentration indices), and generated projections to 2034. Findings Global QCI increased modestly since 1990, but substantial cross-national heterogeneity persisted and widened. High-SDI settings generally achieved the highest QCI with narrowing female-male differences, whereas many low and lower-middle SDI countries stagnated or declined. QCI was consistently lower at older ages, consistent with late presentation and constrained advanced care. Projections suggest incremental gains approaching a plateau by the early 2030s, with persistent dispersion between countries through 2034. Interpretation HBV care quality is improving but not equitably. Accelerating progress will require integrated, One Health-oriented actions: sustaining timely infant vaccination (including birth dose) and prevention of mother-to-child transmission, expanding decentralized testing with reliable linkage to affordable antiviral therapy, and strengthening primary care, supply chains, and data systems to target under-performing populations. These measures provide a pragmatic path to narrowing QCI gaps and advancing the 2030 elimination targets.