BackgroundIntegrated 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 centres. This study examines the cost of organising 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.MethodsA 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 start-up 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.ResultsA 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 centres. Labour 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.ConclusionsThis is the first study to evaluate the costs of integrated, decentralised 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.
Purpose Improvements in childhood survival rates have been achieved in low- and middle- income countries that have made a commitment to improve access to cancer care. Accurate data on the costs of delivering cancer treatment in these settings will allow ministries of health and donors to accurately assess and plan for expansions of access to care. This study assessed the financial cost of treating two common pediatric cancers, nephroblastoma and Hodgkin lymphoma, at the Butaro Cancer Center of Excellence in rural Rwanda. Methods A microcosting approach was used to calculate the per-patient cost for Hodgkin lymphoma and nephroblastoma diagnosis and treatment. Costs were analyzed retrospectively from the provider perspective for the 2014 fiscal year. The cost per patient was determined using an idealized patient receiving a full course of treatment, follow-up, and recommended social support in accordance with the national treatment protocol for each cancer. Results The cost for a full course of treatment, follow-up, and social support was determined to be between $1,490 and $2,093 for a patient with nephroblastoma and between $1,140 and $1,793 for a pediatric patient with Hodgkin lymphoma. Conclusion Task shifting, reduced labor costs, and locally adapted protocols contributed to significantly lower costs than those seen in middle- or high-income countries.
Despite increasing recognition about the stigma associated with cancer screening, diagnosis, and treatment-seeking behaviors, there has been relatively little attention paid to how to assess and intervene to reduce that stigma. An index to measure cancer stigma could empower health program developers and policymakers by identifying the key areas in which a population could benefit from education to change perceptions and address misinformation. The index also could be used to rank countries and communities based on their level of cancer stigma to assess where interventions are needed. We used structured literature review and expert review to generate a cancer stigma item pool. The item pool was subject to cognitive interviews for cultural appropriateness and comprehension; and data from initial pilot testing were used to reduce the pool of items for translation and field testing. The field test was conducted using a web-based survey in four samples representing two regions and three languages-English and Arabic speakers in Jordan and Egypt, and English and Mandarin Chinese speakers in China. Factor analyses and item response theory were applied to finalize the index. The analyses resulted in a 12-item cancer stigma index (CSI) that was reliable across all four samples. The CSI scores were highly correlated with a general illness stigma scale, and operated as expected noting higher cancer stigma among men and those with lower income. The CSI can be used to inform initial cancer education efforts, identifying overall stigma levels in a country or community and particular issue areas requiring intervention.
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