Attached Files:
Cost of Integrated Care | BMJ Global Health | Volume 4 5 MB

“We previously have demonstrated the feasibility and validity of nurse-performed diagnosis and management of such complex conditions as type 1 diabetes and heart failure. These results now support the affordability of this approach and will be useful considerations in the advocacy for implementation of such models in similar settings.”


Background: Integrated clinical strategies to address non-communicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention and treatment of common conditions at primary health centers. This study examines the cost of organizing integrated nurse-driven, physician-supervised chronic care for more severe NCDs at an outpatient specialty clinic associated with a district hospital in rural Rwanda. Conditions addressed included type 1 and type 2 diabetes, chronic respiratory disease, heart failure and rheumatic heart disease.

Methods: A retrospective costing analysis was conducted from the facility perspective using data from administrative sources and the electronic medical record systems of Butaro District Hospital in rural Rwanda. We determined initial startup and annual operating financial cost of the Butaro district advanced NCD clinic for the fiscal year 2013–2014. Per patient annual cost by disease category was determined.

Results: A total of US$47 976 in fixed start-up costs was necessary to establish a new advanced NCD clinic serving a population of approximately 300 000 people (US$0.16 per capita). The additional annual operating cost for this clinic was US$68 975 (US$0.23 per capita) to manage a 632-patient cohort and provide training, supervision and mentorship to primary health centers. Labor comprised 54% of total cost, followed by medications at 17%. Diabetes mellitus had the highest annual cost per patient (US$151), followed by heart failure (US$104), driven primarily by medication therapy and laboratory testing.

Conclusions: This is the first study to evaluate the costs of integrated, decentralized chronic care for some severe NCDs in rural sub-Saharan Africa. The findings show that these services may be affordable to governments even in the most constrained health systems.