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.

Introduction Non-communicable diseases (NCDs), including cardiovascular, diabetes, and chronic respiratory diseases, are an increasing global health burden. Over 70% of deaths globally are attributed to NCDs, the majority of which occur in low-and middle-income countries (LMICs) [1, 2]. In 2016, NCDs accounted for about 46% premature mortality among the population aged less than 70 years [3]. Within the next decade, Africa is projected to experience the largest relative increase in the population living with NCDs, with NCDs taking over as the leading cause of death [4] Without adequate intervention, the increasing NCD burden will cause additional constraints to health systems that are notably already overstretched and fragile [5]. This fragility is even more pronounced in rural areas where poor case detection, access to care, and documentation of NCDs has led to frequent underestimation and under-prioritization of the endemic burden of NCDs. Despite the increasing NCD burden, most people in LMICs have poor availability and access to the NCD medicines that are crucial for prevention and treatment [6, 7]. In addition, existing evidence indicates that access and availability are disproportionate among the rural population compared to the urban population [8] and public facilities compared to private facilities [9]. Thus, the majority of patients residing in rural Africa and relying on public facilities for health care remain untreated or receive delayed NCD treatment.

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