Cost of Integrated Chronic Care for Severe Noncommunicable Diseases at District Hospitals in Rural Sub-Saharan Africa

Background: Integrated clinical strategies to address noncommunicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention of behavioral risk factors and treatment of common conditions at primary health centers. This study examines the cost of decentralizing integrated nurse-driven, physician-supervised chronic care for more severe NCDs to outpatient specialty clinics associated with district hospitals in rural Rwanda. Conditions addressed included type 1 and type 2 diabetes, chronic respiratory disease, and heart failure.   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 cost of the Butaro district advanced NCD clinic for the fiscal year 2013-2014. Per-patient annual cost by disease category were determined. Findings: A total of $51,444 U.S. dollars (USD) in startup costs was necessary to establish a new advanced NCD clinic serving a population of approximately 300,000 people ($0.2 per capita). The annual operating cost for this clinic was $68,040 USD ($0.3 per capita) to manage a 632-patient cohort and provide training, supervision, and mentorship to primary health centers. Labor comprised 53% of total cost, followed by medications at 17%.  Diabetes mellitus had the highest annual cost per patient ($151 USD), followed by heart failure ($104 USD), driven primarily by medication therapy and laboratory testing. Interpretation: 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. Funding Statement: The authors declare: None. Declaration of Interests: The authors declare: None. Ethics Approval Statement: Ethical approval was obtained by the Rwanda National Ethics Committee and Institutional Review Board of Brigham and Women’s Hospital.