Rapid cost-effectiveness analysis: hemodialysis versus peritoneal dialysis for patients with acute kidney injury in Rwanda.

BACKGROUND: To ensure the long-term sustainability of its Community-Based Health Insurance scheme, the Government of Rwanda is working on using Health Technology Assessment (HTA) to prioritize its resources for health. The objectives of the study were to rapidly assess (1) the cost-effectiveness and (2) the budget impact of providing PD versus HD for patients with acute kidney injury (AKI) in the tertiary care setting in Rwanda. METHODS: A rapid cost-effectiveness analysis for patients with AKI was conducted to support prioritization. An 'adaptive' HTA approach was undertaken by adjusting the international Decision Support Initiative reference case for time and data constraints. Available local and international data were used to analyze the cost-effectiveness and budget impact of peritoneal dialysis (PD) compared with hemodialysis (HD) in the tertiary hospital setting. RESULTS: The analysis found that HD was slightly more effective and slightly more expensive in the payer perspective for most patients with AKI (aged 15-49). HD appeared to be cost-effective when only comparing these two dialysis strategies with an incremental cost-effectiveness ratio of 378,174 Rwandan francs (RWF) or 367 United States dollars (US$), at a threshold of 0.5 × gross domestic product per capita (RWF 444,074 or US$431). Sensitivity analysis found that reducing the cost of HD kits would make HD even more cost-effective. Uncertainty regarding PD costs remains. Budget impact analysis demonstrated that reducing the cost of the biggest cost driver, HD kits, could produce significantly more savings in five years than switching to PD. Thus, price negotiations could significantly improve the efficiency of HD provision. CONCLUSION: Dialysis is costly and covered by insurance in many countries for the financial protection of patients. This analysis enabled policymakers to make evidence-based decisions to improve the efficiency of dialysis provision.

Use of a Facilitated Group Process to Design and Implement a Group Antenatal and Postnatal Care Program in Rwanda.

INTRODUCTION: The government of Rwanda is exploring strategies that may reduce the incidence of prematurity and low birth weight. Large-scale implementation of group antenatal care (ANC) and postnatal care (PNC) within the context of the Rwanda national health care system is under consideration. To launch a cluster randomized controlled trial of group ANC and PNC in 5 districts in Rwanda, the implementation team needed a customized group care model for this context and trained health care workers to deliver the program. PROCESS: Adapting the group ANC and group PNC model for the Rwandan context was accomplished through a group process identical to that which is fundamental to group care. A technical working group composed of 10 Rwandan maternal-child health stakeholders met 3 times over the course of 3 months, for 4 to 8 hours each time. Their objectives were to consider the evidence on group ANC, agree on the priorities and constraints of their ANC delivery system, and ultimately define the content and structure of a combined group ANC and PNC model for implementation in Rwanda. The same group process was employed to train health care workers to act as group ANC facilitators. OUTCOMES: A customized group ANC and PNC model and guidelines for its introduction were developed in the context of a cluster randomized controlled trial in 36 health centers. Descriptions of this model and the implementation plan are included in this article. DISCUSSION: Our experience suggests that the group process fundamental to successful group ANC and PNC is an effective method to customize and implement this innovative health services delivery model in a new context and is instrumental in achieving local ownership.

Going beyond incentivizing formal health providers: Evidence from the Rwanda Community Performance-Based Financing program.

Pay-for-performance programs are introduced in an increasing number of low- and middle-income countries with the goal of reducing maternal and child mortality and morbidity through increased health service utilization and quality. Although most programs incentivize formal health providers, some constraints to utilization might be better alleviated by incentivizing other actors in the health care system. This paper presents results from a randomized controlled trial set to evaluate the effects of two incentive schemes that were introduced on top of Rwanda's national Performance-Based Financing program at the health facility level. One scheme rewarded community health worker cooperatives for the utilization of five services by their communities. The second scheme provided in-kind transfers to users of three services. The analysis finds no impact of the cooperative performance payments on coverage of the targeted services, behaviors of community health workers, or outcomes at the cooperative level. Although health centers experienced frequent stock outs of the gifts, the demand-side intervention significantly increased timely antenatal care by 9.3 percentage points and timely postnatal care by 8.6 percentage points. This study shows that demand-side incentives can increase service utilization also when provided in addition to a supply-side pay-for-performance scheme.

The health system cost of post-abortion care in Rwanda.

Based on research conducted in 2012, we estimate the cost to the Rwandan health-care system of providing post-abortion care (PAC) due to unsafe abortions, a subject of policy importance not studied before at the national level. Thirty-nine public and private health facilities representing three levels of health care were randomly selected for data collection from key care providers and administrators for all five regions. Using an ingredients approach to costing, data were gathered on drugs, supplies, material, personnel time and hospitalization. Additionally, direct non-medical costs such as overhead and capital costs were also measured. We found that the average annual PAC cost per client, across five types of abortion complications, was $93. The total cost of PAC nationally was estimated to be $1.7 million per year, 49% of which was expended on direct non-medical costs. Satisfying all demands for PAC would raise the national cost to $2.5 million per year. PAC comprises a significant share of total expenditure in reproductive health in Rwanda. Investing more resources in provision of contraceptive services to prevent unwanted or mistimed pregnancies would likely reduce health systems costs.