Impact and costing of cardiovascular disease treatmentin Kwara State Health Insurance (KSHI) program. University of Ilorin Teaching Hospital (UITH) Amsterdam Institute for International Development (AIID) Amsterdam Institute for Global Health and Development (AIGHD) Oladimeji Akeem BOLARINWA (FWACP) 18th March 2016, Abuja, Nigeria APHPN Conference Wat zijn NCDs?

Why research on cardiovascular disease prevention in HIF program Nigeria? Cardiovascular disease is the most important cause of death worldwide Over 80% of CVD-related mortality occurs in low- and middle income countries In Nigeria, 7% of all deaths are caused by cardiovascular diseases Hypertension is the leading risk factor for cardiovascular disease In Nigeria, the age-standardized prevalence of hypertension is 22% Reduction in systolic blood pressure leads to major health benefits A decrease of 10 mmHg in systolic blood pressure at the population level is associated with a 38% reduction in the risk of stroke and a 26% reduction in the risk of ischemic heart disease

Why research on cardiovascular disease prevention in HIF program Nigeria? Hypertension is an important health problem in target population Prevalence of > 20% in target population Kwara program Hypertension and diabetes among most frequent reasons to visit clinic in KSHI program Insurer and healthcare providers: important topic Doctors mainly trained in infectious diseases Clinics not organized to provide chronic care Treatment of chronic conditions requires a functioning health system Consistent healthcare financing, high quality of care and long-term access to care for patients. Litmus tests for the health system

How can health insurance be used for cardiovascular disease prevention in sub-Saharan Africa?

Evaluation of supply side quality improvements: the feasibility of cardiovascular disease prevention guidelines within the insurance program Operational research project in a primary and secondary program clinic Implementation of international CVD prevention guidelines as part of the supply side quality improvements of the program Prospective cohort study of 349 patients at risk for CVD (patients with hypertension, diabetes, renal disease and established CVD), follow up 1 year Main outcomes: 1. Quality of care 2. Costs of care (healthcare provider perspective)

High quality of CVD prevention care in Ogo Oluwa Hospital Majority of patients (95%) had hypertension Implementation of cardiovascular prevention care improved the general clinic management Improved administration patient disease courses Improved clinic organization Laboratory quality control Upgraded test equipment  Other patients also benefit from these improvements

Demand side: impact of the KSHI program on hypertension outcomes 3 household surveys in 2009, 2011, 2013: 559 hypertensive adults at baseline (program 309, control 250) Complete follow up data for 332 adults (program 194, control 138) Effect of Kwara State Health Insurance measured in people identified with high blood pressure during the baseline survey Primary outcome: blood pressure reduction

Early impact on mean blood pressure in the population with hypertension

Sustained impact on mean BP in the population with moderate/severe HT

Long term impact due to higher quality of hypertension treatment in program area? Treatment coverage for hypertension in two areas similar -> difference in quality? Number of respondents treated for hypertension who obtained drugs in formal* health facility Program area 84% Control area 43% Treatment in informal** facility did not show any significant blood pressure reduction compared to no treatment *Formal facility: public and private hospitals and clinics, primary healthcare centers, private physicians and nurses, and pharmacists **Informal facility: patent medicine vendors and traditional medicine practitioners and vendors

Costs of CVD prevention care from a program clinic perspective Micro-costing study using data from the QUICK I cohort Use of clinical pathways to identify all cost items of CVD prevention care (hypertension and diabetes care)  determine utilization and unit price of each item to calculate costs of care Scenario analyses: hypothetical scenarios to estimate the effect task-shifting, less frequent monitoring of patients, less diagnostic testing, polypill* for hypertension on total costs *Polypill refers to a pill that combines several CVD prevention drugs in a single pill, Usually 2 or 3 antihypertensive drugs, a statin and sometimes asperin.

Use of clinical pathways to identify all cost items of CVD prevention care (hypertension and diabetes care)  determine utilization and unit price of each item to calculate costs of care

Direct costs can be reduced in hypothetical cheapest scenario by 42% Scenario analyses: hypothetical scenarios to estimate the effect task-shifting, less frequent monitoring of patients, less diagnostic testing, polypill for hypertension on total costs

Conclusion: health system litmus test passed Implementation of guidelines for the treatment of cardiovascular risk factors resulted in high quality of care, comparable to quality of care observed in high-income countries. The insurance program improved the health of the hypertensive population in the program area. Blood pressure fell significantly more in the communities with health insurance compared to communities without health insurance. Test innovative service delivery models to reduce costs of care: task-shifting, simplification of treatment protocols, (partial) monitoring in community (via remote health posts?)