MGHD 2021

Background: Breast cancer is the most diagnosed cancer worldwide with approximately 2.3 million new cases recorded in 2020. Breast cancer survival rates are low in low- and middle income countries (LMICs) because of late-stage diagnoses, and inadequate resources for diagnosis and treatment. In Rwanda, studies have shown that more 70% of breast cancer patients are diagnosed at late stage. With the aim of downstaging breast cancer in Rwanda, a breast cancer early detection program initiated in Burera District of Rwanda in 2015 showed an increase in early stage diagnoses. However, the cost of implementing this program is unknown. Objective: To determine the health system cost of the Breast Cancer Early Detection (BCED) program in Burera district from April 2015 to April 2017. Methods: Cross-sectional study included patients’ visits at seven health centers in Burera district and Butaro Cancer Center of Excellence (BCCOE) at Butaro district hospital from April 2015- April 2017. Direct observation and secondary data review were used during data collection. A costing analysis was done using Time Driven Activity Based Costing methodology to calculate the total cost of the BCED program. The allocated cost of each resource used in the BCED program was calculated and the total cost per patient visit was obtained from the sum of the cost of all resources utilized by patients undergoing the care cycle of the BCED program. Results: From April 2015 to April 2017 a total of 1220 patients’ visits in the BCED program were recorded. Out of 1220 visits, 1010 (83%) were health center visits while 210 (17%) were visits to BCCOE, the district’s hospital. The median of the total allocated cost per patient visit for all resources used at the health center level was $3.27, and $58.93 at referral level. The highest cost drivers per patient visit were personnel with a median cost of $1.60 (49%) across health centers, and consumables at $27.29 (46.3%) at the hospital level. The lowest cost drivers at health center and BCCOE level were indirect costs at $0.10 (3%) and drugs at $0.83(1.4%) respectively. Conclusion: The cost per patient visit in the BCED program at health centers was similar to previous cost analyses of other outpatient department services in rural health centers in Rwanda. However, variations in resource utilization such as using different cadres of personnel led to slight cost differences across health centers. At BCCOE level, some inefficiencies were due to shortage of providers available to process biopsy, requiring patients to have two hospital visits rather than one for diagnostic services. From our findings, a recommendation to decentralize some preliminary diagnostic services to district hospital was made.