This cost analysis sought to estimate, from the provider perspective, the annual cost of RHD care in a tertiary centre in the Western Cape Province of South Africa. RHD was estimated to cost GSH about US$ 1.9 million in the year 2017. These costs represent 11.2% of the total budget for GSH in the year 2017. Triangulating these estimates with data from the REMEDY registry, RHD was estimated to cost US$ 3900 per patient per year in total, with most of the total cost being driven by surgical theatre and cardiac catheterization laboratory costs. These costs are much higher than the annual cost of the facility-level care delivery of HIV/AIDS, drug sensitive tuberculosis, and hypertension, which have been estimated at around US$ 660 (in 2016) , US$ 250 (in 2015) , and US$ 260 (in 2016)  per year, respectively. Not only has managing RHD cost more on a per-patient basis than all three of these conditions combined, but it has also been more neglected in national health policy discussions .
To the best of our knowledge, there have been no previous costing studies on RHD in Africa and, only one prior costing study in a low- and middle-income country setting. Terreri et al., looking at RHD in Brazil, quantified per-patient direct costs of RHD and rheumatic fever from the provider perspective using the ingredients approach . Even after adjusting to a common currency and year, the cost estimates in this study are higher than in the Brazilian study, probably due to advances in care (i.e. new technologies) and to the fact that health sector prices tend to rise faster than inflation. In addition, the present study took a more detailed look at surgical care, the most expensive aspect of RHD care.
This study assessed the cost of RHD to the public sector. It did not include ambulatory costs or admission costs from the private sector. It also did not look at patient costs, including so-called “direct non-medical costs” like transport and food, which – from a societal perspective – are a significant share of healthcare costs in South Africa . However, the direct medical costs were still substantial, and from a societal perspective, the cost of surgical care from the provider perspective is probably the most significant single driver of costs.
It should be noted that, amongst the “direct” costs estimated using the ingredients approach, the main cost contributors to outpatient RHD care were monthly medications followed by personnel cost, while the cost of laboratory tests, personnel and blood transfusions were major drivers for inpatient medical and ICU ward costs. These findings are similar to a study from Australia in which two-thirds of the cost of ICU care in tertiary hospitals was related to personnel . Rechner and Lipman (2005) predicted that consumables expenditure (in general) is likely to increase in the future in light of new innovations and therapies. Along these lines, the cardiac catheterization lab and surgical theatre consumables were found to be major drivers of cost in this study. One implication of this study is that research on developing cheaper, locally made prosthetic valves and catheters should be supported, and measures should be taken to support the production and export of such products to other African countries .
This study can also be viewed as an analysis of the economic consequences of inadequate prevention of rheumatic fever and RHD. RHD can be entirely prevented by addressing bacterial sore throat in children using primary health centre-based approaches. When this prevention window is missed, rheumatic fever develops and can lead to heart valve damage, which can require one or more surgeries over the lifetime of affected individuals. Several programs in Latin America and the Caribbean demonstrated that healthcare costs from RHD declined by more than 90% when comprehensive prevention efforts were undertaken . However, barriers such as poor access to primary care, shortage of skilled staff and poor public awareness about diagnosis and treatment of sore throat hindered wide adoption of primary prevention of the disease. The present study provides crucial evidence for the Western Cape Department of Health, and the National Department of Health to scale up RHD prevention efforts in South Africa.
Our study had a number of important limitations. First, it was a hospital-based cost analysis, with the usual limitations of such a study design. One hundred patient records were reviewed; however, some details were missing, while those with severe disease were often presented with little detail. Nevertheless, considerable effort was taken to produce accurate and relevant estimates. Second, medication records did not disaggregate drugs related to RHD from drugs with other indications, potentially leading to over-estimates of RHD-specific medication costs. Third, out of the 100-participant sample, only 88 individuals were consistently engaged in RHD care in GSH. This finding raises the question of whether they were receiving care elsewhere. As noted previously, for practical reasons, we were unable to gather pharmacy dispensing or emergency department costs. In total, these factors might lead to an under-estimate of per-patient costs and GSH costs. Finally, the step-down approach is not ideal for estimating some costs such as diagnostics (echocardiography, etc.) and pharmacy costs; better data would allow for more precise estimates of these costs using an ingredients approach. Notably, the cost of pharmacy services is likely to be higher at GSH than at health facilities in the community where most individuals with RHD receive the majority of their monthly prescriptions. Overall, our estimates of average annual per-patient care costs are probably higher compared to what they would have been if referring hospitals and clinics had been sampled.