Cost-minimization Analysis for Kidney Dialysis Services in Tuvalu

BACKGROUND. Tuvalu has high rates of risk factors for chronic kidney disease (CKD)—e.g. diabetes, hypertension—and a limited health budget to address non-communicable disease (NCD) treatment and prevention. CKD patients who need dialysis are transferred to Fiji, where they receive dialysis for the remainder of their lives. The Tuvaluan government pays all health and many non-health expenses (e.g. housing, a living stipend, and air travel to Fiji for patients and caregivers) for dialysis patients. In 2016, expenses for 12 dialysis patients accounted for 7.6% of total government health expenditures. Tuvalu is interested in lower-cost alternatives, including creating a local dialysis center on Tuvalu’s main island. The government recently issued a request for proposals, receiving the first from an Indian medical company.

METHODS. We conducted a cost-minimization analysis from the Tuvaluan government perspective, comparing the cost of maintaining the status quo—treating dialysis patients in Fiji—against the cost of implementing a dialysis center in Tuvalu for a 20-year time horizon. To facilitate the analysis, we created an Excel-based tool that assesses the cost of establishing, operating, and maintaining a dialysis center. The tool contains a set of modifiable assumptions about infrastructure, furniture, medical equipment, health personnel, lab services, medicines, consumables, maintenance, and other inputs for a dialysis center, as well as unit costs for each item. We used the tool to compare the costs of continuing the status quo against several alternative treatment scenarios. We also assessed health system bottlenecks that could impede implementation of a dialysis center in Tuvalu. Alternative dialysis treatment scenarios assumed that the Indian company’s proposal would be implemented for the first five years, after which Tuvalu would staff and operate the facility.

RESULTS. Over the 20-year time horizon, we found that if only eight patients are healthy enough to return to Tuvalu for dialysis, with the remainder needing to be treated in Fiji, costs would be 266,000 AUD higher than the status quo of receiving dialysis treatment in Fiji. Although, another scenario assumed that all 12 of Tuvalu’s current dialysis patients could return to Tuvalu and receive dialysis treatment, resulting in net savings of almost 476,000 AUD over 20 years. Still, investment in the dialysis center in Tuvalu would not break even until 12 years after implementation. Several bottlenecks would need to be overcome, including limited rainwater supply to support dialysis, high nursing turnover, and a lack of qualified biomedical technicians to maintenance equipment.

SUMMARY. Because the Tuvalu health system has limited capacity to treat severe complications experienced by many dialysis patients, our most realistic alternative scenario assumed that at least one-third of current and future dialysis patients would need to remain in Fiji for treatment. If only eight of 12 patients return to Tuvalu, then building a dialysis center would result in higher costs to the Tuvaluan government. Should Tuvalu continue to pursue the development of a local dialysis center, we recommend that the government seek more favorable proposals, while also deliberating whether NCD prevention may more effectively reduce dialysis costs by decreasing the need for dialysis.