Introduction The Zanzibar islands are a semi-autonomous country made up of two sister islands. Population is 1.5 million with the majority living in urban areas. The main referral hospital is based on Unguja island and this is the only hospital with rheumatology care and where disease modifying anti-rheumatic drugs (DMARDs) can be prescribed although there is no rheumatologist on either island. Healthcare is free for the population of Zanzibar. However, DMARD therapy is not included in the essential drugs list and patients incur significant out-of-pocket expenses when accessing care. A cost-effective analysis of DMARD therapy has not been performed. The aim of the project is to assess the efficacy of a basic healthcare package for this disease group to be included in the Zanzibar essential healthcare package.
Methods From September 2019 and ongoing, all patients with a clinical diagnosis of rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis were informed of the study and asked to participate. Patients were managed according to an internationally accepted pre-defined treatment guidelines. Data were collected on disease severity, medication used, quality of life scores using the EuroQol 5 dimensions-5 levels (EQ5D5L) questionnaire as well as income and expenditure for health. Data will be inputted in the Fair Choices tool developed by the Bergen Center for Ethics and Priority Settings (BCEPs) for calculations to determine the cost effectiveness of the package.
Results Preliminary results show that increasing combination therapy coverage to 100% for moderate to severe rheumatoid arthritis with low-dose corticosteroids, folic acid supplementation, DMARDS (including methotrexate) was found to have an increased cost of USD 414,381. The incremental cost effectiveness ratio (ICER) per quality adjusted life year was 5.45 suggesting the package to be cost-effective. This would avert 76096 disease adjusted life years (DALYs).
Discussion Preliminary analysis shows combined therapy for rheumatoid arthritis to be cost effective. To our knowledge, this is the first study of its kind to be undertaken in Zanzibar. Data collection is ongoing, and we hope to present more robust data from other parameters and a larger sample size at the time of the conference.
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