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Patient management costs and coronavirus

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KWAME OWINO

By KWAME OWINO
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LEO KEMBOI

By LEO KEMBOI
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During one of the updates on the emergency facing Kenya today, the PS in the Ministry of Health stated that it costs the government up to Sh1 million to provide treatment to every patient who is hospitalised due to Covid-19.

This claim was intended to make Kenyans understand the danger of infections and the risks that come from a disease that spreads very easily and also has a high lethality level.

Thus, the statement on the cost of treating every infection was to alert the public to the economic burden attached to its treatment.

That statement was well-intended but it is evident that the estimate declared is wrong. These estimates are unlikely to be accurate for four reasons that we state below.

First, only the most critically ill of the people infected with this virus would require hospitalisation within an ICU facility.

An ICU facility is expensive because of specialised equipment and the degree of care that clinicians and other staff must provide, in addition to the equipment required to sustain that life.

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Even assuming that the permanent secretary was only referring to the costs related to the most affected patients who would need specialised wards, beds, mechanical ventilation and highly specialised medical professionals, the numbers still fail to support that cost.

The economics of running an ICU can be divided into two portions and these are the fixed and variable costs.

The fixed cost relates to human resources, the specialised equipment and the ward management costs.

Therefore, critical care management in an ICU facility take up over 80 per cent of total costs in an ICU facility.

These are called fixed costs because the provision of the bed, the space, the doctors, nurses and pharmacists are incurred upon establishment.

They are not variable costs because the specialists at the public facilities constitute the largest cost for caring of an ICU patient.

By example, if a facility has 20 ICU spaces, then the fixed costs are incurred irrespective of whether patients fill them or not.

It is this peculiar economics of the ICU that makes it difficult for public sector hospitals to establish idle ICU capacity given the great demand for the same resources during an epidemic.

Variable costs come from the medication, disposal equipment and the duration of patient stay and any rehabilitation costs during recovery.

Staffing in the ICU facility is essential and the degree of specialisation determines what it costs to provide this kind of care.

Second, in seeking to justify the claims, the PS added that the costs are driven up by the prices of the equipment required within the facility and the frequency of their use.

The lethality of the SarsCov-2 requires that all medical staff attending to patients be provided with Personal Protective Equipment (PPE).

In the estimation of the PS, PPE, which comprises of a full body suit, boots, gloves and protective visor, cost about Sh10,000 per unit. This estimate for PPE is wildly above the figures that are available.

For instance, a cursory check with Amazon and Alibaba websites showed that suits that have been approved by the Federal Drugs Administration (FDA) of the US and are available for immediate export, lie in the range of Sh250 to Sh3,000 for high-end ones and the full gown and kit average Sh4,000.

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What the cited figures demonstrate is perhaps the inefficiency of public procurement in Kenya where government purchases goods at outrageous rates from favoured suppliers.

Third, having stated a very high cost for PPE suits, the PS made the situation worse by stating that the equipment is used only once and that the clinicians have to change into a new set while attending to every patient under care.

We searched for the practice manuals and Rapid Advice Guidelines prepared by the World Health Organisation and spoke to a few professionals in Kenya.

Our references showed that not only is there no requirement for a clinician to change suits with every patient but also that there is no advantage to visit the patient several times daily.

Most of the care is left in the hands of very capable nursing staff and pharmacists once the attending colleague has reviewed progress and provided care instructions.

If it is true that every doctor in Kenya’s public health system is required to visit patients several times a day and all staff required to change into new PPE with every attendance, then this is luxurious attendance that is wasting acutely needed resources.

Some of the PPE equipment is disposable but the nursing and attending doctors do not add to effectiveness of care by changing them every hour.

At the same time, the extreme shortage of these professionals means that they are made to waste time by changing again and again when they can take adequate care of their patients and preserve their equipment well.

Therefore, it appears that the statement could be read as an advertisement of wastage.

Fourth, operational costs and maintenance are unlikely to have changed in the short term, especially because there is no evidence that government has suddenly expanded human resources in the health sector.

What this implies is that it is incredibly difficult to change the economics of the ICU management in any health system by shifting costs on the variables costs alone.

That there is a need to increase human and other resources in health is evident, but ICU attendance to patients in the short and medium term will not alter costs adversely.

While managing the emergency from the Covid-19, the credibility of statements from the government matter.

And while it essential to be candid about the social and economic costs that are borne from this illness, the arguments should be sensible and real.

So in citing that the marginal ICU patient imposes a cost of Sh40,000 per day on the public sector’s resources, it ought to be clarified that most of this is not an incremental cost per se because the fixed costs have already been incurred.

Perhaps the PS should start by asking the health economists in the Health ministry to be more transparent about the costs that they make her cite in public.

Kwame Owino is the CEO of the Institute of Economic Affairs, a think tank on public affairs based in Kenya; Leo Kemboi is an assistant programme officer at the Institute of Economic Affairs.





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