Cost of care for patients on maintenance haemodialysis in public facilities in Cameroon

Background: The management of end-stage kidney disease constitutes a heavy burden on communities worldwide due to the high cost of renal replacement therapy (RRT). Data on the cost of RRT are scanty in low-income countries. This study aimed to evaluate the global cost of haemodialysis in Cameroon, an emerging economy in Central Africa. This will provide data to help healthcare planners develop more cost-effective strategies for the care of these patients. Methods: A prospective cost analysis of chronic haemodialysis care in three public-sector facilities was conducted in Cameroon. Both incident and prevalent patients were enrolled and followed up for 6 months. Patient data and costs were collected from patient interviews, medical records, bills, hospital price-lists and the procurement departments of the hospitals. Direct medical costs included outpatient consultation fees, dialysis consumables, dialysis session fees, drugs, laboratory and radiological tests. Non-medical direct costs included the cost of transport, feeding, water and electricity. Indirect costs related to the monthly loss of productivity for patients and their caretakers. The annual costs were calculated as the median costs for 6 months multiplied by 2 and were expressed in the local currency, the Central African franc (XAF), and US dollars ($). results: A total of 154 patients (62.3% males), mean age of 46.8 ± 15.2 years, were included, with 6 130 dialysis sessions completed during the study period. The annual median cost of haemodialysis per patient was XAF 7 988 800 ($ 13 581). Out-of-pocket payments amounted to XAF 2 420 300 ($ 4 114), accounting for 30% of the total cost. The median direct cost was XAF 7 458 200 ($ 12 679) and indirect cost XAF 530 600 ($ 902). Direct medical costs accounted for 88%, mainly due to dialysis consumables. In the initiation phase, additional costs of $ 754 were incurred. The cost of hospitalization, laboratory and radiology tests, feeding, consultation fees and some drugs varied significantly among facilities. conclusions: Compared to the national gross domestic product per capita in Cameroon, the cost of care of patients on haemodialysis is high. Out-of-pocket payments are out of the reach of most patients and there is a need for implementing other cost-effective strategies to prevent and manage end-stage kidney disease in our setting.


INtrODUCtION
The availability of renal replacement therapy (RRT) such as dialysis and transplantation for the treatment of endstage renal disease (ESRD) has been one of the great successes of medicine in past decades. It has been available in high-income countries for more than 50 years, with rapid growth in the number of people treated [1,2]. cination. All these additional costs are borne by patients and their families. This study aimed to evaluate the global cost of ESRD treated by HD in a resource-limited country, to help healthcare planners to develop strategies to minimize the cost of care of these patients.

MEtHODs
A prospective cost-analysis of HD care was conducted in 3 facilities in Cameroon (two tertiary, one regional). All centres are equipped with Fresenius 4008S dialysis machines, use consumables produced by the manufacturers and do not practise dialyzer reuse. In these centres, as in other centres in Cameroon, patients undergo two dialysis sessions of 4 hours per week.
We included consenting incident and prevalent patients on HD for ESRD and followed them up for 6 months from November 2012 to April 2013. Outcomes of interest were expenditure by patient or their families as well as by the hospital in relation to HD care. Staff salaries and other utilities, furniture and cost of maintenance of the building were excluded from the analysis. Data and costs were obtained from patient interviews, medical records, bills, hospital price-lists and procurement departments of the hospitals. Direct costs analysed included direct medical costs (dialysis session fees, cost of consumables, drugs, outpatient consultation fees, laboratory and radiological tests) and direct non-medical costs (transport, feeding, water and electricity). One indirect cost considered was the monthly loss of productivity for patients and their caretakers estimated from the time spent for the treatment. Out-of-pocket payments (borne by patients and families) included dialysis session fees, vascular access, all drugs, laboratory and radiology tests, vaccinations, meals and transportation. All other costs were borne by the government/hospital. The cost of incident patients was used to calculate the cost at the initiation phase. The cost of electricity and water was calculated with the assistance of an engineer at each hospital. Electricity consumption was calculated by taking into account all electrical appliances at each unit, consumption by each appliance, and the duration of its usage per month. Water consumption was calculated by multiplying hours of dialysis by the hourly water usage per dialysis machine, and the number of machines at each dialysis unit.
Data analysis used SAS/STAT ® v 9.1 for Windows (SAS Institute Inc., Cary, NC, USA). We reported results using counts and percentages, means and standard deviations (SD) or median (min-max). Comparisons across study centres were made using the chi-squared test and analysis of variance (ANOVA). Costs were expressed as the median of the expenditure recorded over 6 months per patient in the local currency) and converted to US dollars, based on the exchange rate at the end of the study (1 XAF = $ 0.0017). We estimated the annual cost by multiplying the median cost by 2. A p-value < 0.05 was considered statistically significant.
The study received administrative authorization from the Douala General Hospital and ethical approval was obtained from the ethical board of Douala University.

rEsULts
Of the 154 participants included, 106 (68.8%) were prevalent and 48 (31.2%) were incident patients. The mean age was 46.8 ± 15.2 years and 96 (62.3%) were males, with no difference between centres. The majority of our patients were in a low socio-economic class with more than 25% without income. Only 9% had medical insurance. The total number of dialysis sessions included was 6130 (mean 39 (Table 2).
In the initiation phase, additional costs of $ 775 were incurred, mainly due to the cost of vascular access, drugs and hospitalization ( Table 3).
The itemized costs at each hospital are shown in Table 4.
cost of haemodialysis in cameroon

DIsCUssION
The reported cost of dialysis varies considerably among regions and countries [7]. Our annual cost was approximately $ 13 581, with out-of-pocket payments accounting for 30%. This is close to that reported in Iran ($ 11 549) [17] but is lower than in most developed countries and some low-income nations. The annual cost of haemodialysis has been estimated at $ 87 500 in the USA [18], between $ 22 000-55 000 in Nigeria [19,20], $ 46 332 in Saudi Arabia [21], $ 27 440 in Tanzania [22] and $ 28 570 in Brazil [23]. One of the reasons for our lower cost is that we did not include the staff and building costs as has been done in other studies.
Lower costs have been reported in low/middle-income countries such as Indonesia ($4900-6500) [24], South Africa ($7000) [16], Sri Lanka ($5869-8804) [25], Sudan ($6847) [26] and India ($3000) [27]. These differences may be explained by many factors including the annual per capita income of countries, the methods used in estimating costs, different management protocols, and differences in local import duties, drugs, laboratory tests and the costs of consumables.
The main contributors to cost in our study were those related to the dialysis procedure and, in particular, the haemodialysis consumables. Similar results were reported in Sri Lanka [28] and in Brazil [23]  when the state subsidizes dialysis, the cost covered by patients is high and the majority cannot afford it. Morbidity and mortality are consequently high [32][33][34][35][36][37][38][39][40][41].
In SSA, poverty is rampant and over 40% of the population is estimated to live on less than one dollar per day [42].
Given the constant increase in the number of patients requiring dialysis in Cameroon, and considering that haemodialysis is the only modality available, it is imperative to identify cost-effective strategies to meet the demand for renal services. There is a need for policymakers in low-income countries to look for ways to reduce the cost of dialysis. One major step could be that governments build infrastructure to produce dialysis supplies and generic medications locally, and remove the import duty charged on dialysis consumables. Renal transplantation, which is a more cost-effective treatment for ESRD, remains underutilized in SSA, and Cameroon in particular, due to lack of qualified health personnel and appropriate infrastructure [43,44]. The most important factor is to reduce the number of patients developing ESRD. Identification and optimal treatment of CKD in high-risk populations, especially in resource-limited settings, remains the only costeffective and sustainable means of curbing the cost of managing ESRD. However, this approach is still in its infancy in most SSA countries and is not subsidized by the state in Cameroon [45][46][47].

CONCLUsIONs
This multi-centre study demonstrated that the global cost of care of patients on haemodialysis in Cameroon is extremely high compared with the national gross domestic product per capita and that it is mainly due to the cost of