Economic burden of severe non-communicable diseases by level of care to inform priority-setting in Tanzania

Abstract Background Noncommunicable diseases (NCDs) account for nearly half of all deaths in Tanzania. To improve access to care for severe NCDs, Tanzania has introduced the PEN-Plus model at primary hospitals. However, evidence on the patient-level economic burden of severe NCD care across diseases and levels of care remains limited. This study estimated patient-level costs for rheumatic heart disease, sickle cell disease, type 1 diabetes mellitus, and type 2 diabetes mellitus and identified key drivers of cost variation. Methods A cross-sectional, prevalence-based cost-of-illness study was conducted among patients receiving outpatient care for type 1 diabetes, type 2 diabetes, rheumatic heart disease, and sickle cell disease at primary and tertiary hospitals in Tanzania. A bottom-up costing approach was used to estimate direct and indirect costs of outpatient care from the patients' perspective. Indirect costs were valued using the human capital approach. Socioeconomic inequality was assessed using concentration indices and generalised linear models with a log link; key drivers of cost variation were identified. Results We included 1,037 participants. The mean annual outpatient cost per patient was USD 255 (95% CI: 242–270). Direct non-medical and indirect costs accounted for most of the economic burden, with transport as the largest cost component (USD 87 per year). Costs varied by disease and level of care. Patients with sickle cell disease incurred the highest direct costs (USD 238 per year). For rheumatic heart disease, mean drug costs increased from USD 3 at primary hospitals to USD 65 per year at tertiary hospitals. Costs were lower at primary hospitals (CR 0.80; 95% CI: 0.72–0.90) and increased with distance travelled. Socioeconomic inequality was minimal at primary hospitals. In contrast, low-income groups had a statistically significantly higher share of patient costs among patients with type 2 diabetes and sickle cell disease attending tertiary hospitals. Conclusion The economic burden of severe NCD care in Tanzania is driven as much by access barriers as by medical costs. Expanding PEN-Plus, reducing transport-related costs, and aligning insurance benefits with long-term care needs could improve financial protection and equity.