Patient and provider cost analysis of integrating rheumatic heart disease care into the primary healthcare system in Northern Uganda.

BACKGROUND

Rheumatic heart disease (RHD) interventions are currently being rolled out in Northern Uganda. We recently evaluated a programme to decentralise secondary antibiotic prophylaxis (SAP) from regional hospitals to primary clinics in Lira and Gulu districts, finding equivalent adherence and high acceptability. The present study evaluated the cost implications of the programme.

METHODS

We prospectively assessed costs from the purchaser, patient, and societal perspectives, comparing unit and total costs before and after programme implementation. We used a mixed costing approach, including ingredients-based and step-down costing for direct and indirect costs (respectively) to the purchaser. We assessed patient costs through exit surveys. Cost data were analysed using descriptive statistics and t-tests for changes after implementation. A sensitivity analyses was done around indirect costs.

RESULTS

The programme reduced purchaser costs for clinical services (overheads, personnel and medications) by over 50% in both districts. Likewise, it significantly reduced patient costs, by lowering transport costs and productivity losses. To enable this, substantial investments were needed for implementation strategies ("programme costs") to support SAP delivery, especially for equipment and training. Our findings were robust in the sensitivity analysis.

CONCLUSION

Compared to current practice, an RHD decentralisation programme reduced the unit cost of SAP to the purchaser, though this was attenuated by higher programme costs. The programme provided financial benefit to low-income households and reduced the volume of RHD care at hospitals. Future projects could seek to reduce programme costs, by streamlining training activities. Our findings can inform the design of RHD programmes in the region.