Analysis of costs in implementing the HEARTS hypertension program in Nigerian primary care.

backgroundThe Nigeria Hypertension Control Initiative (NHCI) program, launched in 2020, integrates hypertension care into primary healthcare using the HEARTS technical package, which includes screening, health counselling, and standardized hypertension treatment protocols. This package has been piloted through NHCI in Kano and Ogun States and in the Federal Capital Territory (FCT) Abuja, as part of the Hypertension Treatment in Nigeria (HTN) project.

objectiveTo assess the costs of scaling up the HEARTS hypertension control package and compare these costs with those of usual care.

methodsData on the costs of implementing the HEARTS program were collected from 15 purposively sampled primary health facilities in Kano, Ogun, and FCT Abuja between February and April 2024. Costs included training, medicines, provider time, and administrative expenses. We used the HEARTS costing tool, an Excel-based instrument, to collect and analyze the annual costs from a health system perspective, using an activity-based approach.

resultsThe estimated annual cost of implementing HEARTS was USD 16 per adult primary care user (PCU), with variations across the three locations: USD 21 in Abuja, USD 11 in Kano, and USD 16 in Ogun. Average annual medication costs per patient treated under HEARTS also varied by location, amounting to USD 28 in Abuja, USD 27 in Ogun, and USD 16 in Kano. Under usual care, annual medication costs per patient were estimated at USD 32 in Kano and USD 16 in Ogun (data for Abuja were unavailable). Major cost drivers for the HEARTS package included provider time (49%) and medication (47%), compared to usual care, where medication alone accounted for 80% of costs. Implementing HEARTS requires a full-time equivalent of 0.45 doctors, 1.59 nurses, and 5.21 community health workers per 10,000 primary care users.

conclusionsIn the Nigerian primary care setting, provider time costs and medication costs emerge as major considerations in scaling up hypertension services. Policy options could consider reducing follow-up visit frequency for well-controlled patients to decrease provider time costs. Additionally, medication costs may be reduced by prioritizing first-line treatments and volume-driven purchasing as program scale-up continues.