Ismaila et al.

BMC Health Services Research (2021) 21:1115

https://doi.org/10.1186/s12913-021-07101-z

RESEARCH ARTICLE Open Access

The cost of clinical management of SARS-

COV-2 (COVID-19) infection by level of
disease severity in Ghana: a protocol-based
cost of illness analysis
Hamza Ismaila1*† , James Avoka Asamani2†, Virgil Kuassi Lokossou3, Ebenezer Oduro-Mensah4,
Juliet Nabyonga-Orem2† and Samuel Kaba Akoriyea1†

Abstract
Background: As the global strategies to fight the SARS-COV-2 infection (COVID-19) evolved, response strategies
impacted the magnitude and distribution of health-related expenditures. Although the economic consequence of
the COVID-19 pandemic has been dire, and its true scale is yet to be ascertained, one key component of the
response is the management of infected persons which its cost has not been adequately examined, especially in
Africa.
Methods: To fill gaps in context-specific cost of treating COVID-19 patients, we adopted a health system’s
perspective and a bottom-up, point of care resource use data collection approach to estimate the cost of clinical
management of COVID-19 infection in Ghana. The analysis was based on the national protocol for management of
COVID-19 patients at the time, whether in public or private settings. No patients were enrolled into the study as it
was entirely a protocol-based cost of illness analysis.
Result: We found that resource use and average cost of treatment per COVID-19 case varied significantly by
disease severity level and treatment setting. The average cost of treating COVID-19 patient in Ghana was estimated
to be US$11,925 (GH¢68,929) from the perspective of the health system; ranging from US$282 (GH¢1629) for
patients with mild/asymptomatic disease condition managed at home to about US$23,382 (GH¢135,149) for
critically ill patients requiring sophisticated and specialised care in hospitals. The cost of treatment increased by
some 20 folds once a patient moved from home management to the treatment centre. Overheard costs accounted
for 63–71% of institutionalised care compared to only 6% for home-based care. The main cost drivers in overhead
category in the institutionalised care were personal protective equipment (PPEs) and transportation, whilst
investigations (COVID-19 testing) and staff time for follow-up were the main cost drivers for home-based care.

* Correspondence: hamzaismaila@gmail.com
†
Hamza Ismaila and James Avoka Asamani co-first authors.
Juliet Nabyonga-Orem and Samuel Kaba Akoriyea co-supervising authors.
1
Ghana Health Service, Headquarters Office, Private Mail Bag, Ministries,
Accra, Ghana
Full list of author information is available at the end of the article

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Ismaila et al. BMC Health Services Research (2021) 21:1115 Page 2 of 10

Conclusion: Cost savings could be made by early detection and effective treatment of COVID-19 cases, preferably
at home, before any chance of deterioration to the next worst form of the disease state, thereby freeing up more
resources for other aspects of the fight against the pandemic. Policy makers in Ghana should thus make it a top
priority to intensify the early detection and case management of COVID-19 infections.
Keywords: Cost of COVID-19, Cost of illness analysis, COVID-19, Case management of COVID-19, Bottom-up, Point
of care resource use, Costing

Background addition to making the wearing face mask compulsory,

In December 2019, an unknown respiratory illness was the country closed its borders, closed down schools and
reported in the Hubei Province of China, a disease later adopted what was termed as the “test, treat and trace (3-
named COVID-19 and caused by Severe Acute Respira- Ts) approach”. The 3-Ts approach approach involved
tory Syndrome Coronavirus type-2 (SARS-COV-2) [1]. rapid and enhanced contact tracing, general surveillance
The disease subsequently spread globally and was de- and testing measures as well as case management in des-
clared a pandemic by the World Health Organization ignated health facilities [13, 14]. Laboratory testing sites
(WHO) in March 2020 [2]. As of 17 September 2020, were increased from one to 10; medical drones deployed
29,679,284 cases were confirmed globally with 936,521 for sample quick transportation; COVID-19 Tracker mo-
deaths while the WHO African Region recorded bile application launched; additional 45,107 health
1,127,164 confirmed cases and 24,294 deaths [3, 4]. workers (1000 as temporal contact tracers) employed;
The global response measures at the time was not uni- 50% salary incentive plus tax exemptions provided to its
form across countries but notably centred on centred on health workforce; and over 7000 health facilities desig-
travel restrictions, evolving into partial and complete nated as treatment centres [15, 16].
lockdowns to drastically limit physical interactions with Although the economic consequence of the COVID-
the intent of curbing the spread of the virus alongside 19 pandemic had been dire, and its true scale yet to be
aggressive testing and treatment of infected persons [5]. ascertained, one key component of the response was the
Other public health and social measures included en- management of infected persons which its cost has not
couraging individuals to observe physical distancing of been adequately examined. Earlier studies in China esti-
1–2 m, use of face masks (or face coverings) when out- mated the mean cost of treating COVID-19 patient from
side of home, regular hand washing or disinfection and a health system perspective to be about US$6827 which
isolation when one was exposed to someone infected. roughly amounted to US$ 0.49 billion for the entire clin-
The World Health Organisation issued varied guidelines ical management of COVID-19 in China [17]. Using a
(updated from time to time) and countries adapted it to similar health system perspective, the World bank gener-
their local context. ated regional averages of US$3.65 for a mild case and
In the initial phase, the Ghanaian authorities, focused US$15.56 for a hospitalized patient in sub-Saharan Af-
on preparedness and response planning in which the rica [18]. However, these estimates were premised on ef-
relevant WHO Guidelines were adapted into a country fective prevention measures (wide scale and intensive
strategy [6]. The strategy prioritised setting up of isola- social distancing) which were not met.
tion/treatment and/or quarantine centres, procurement There are very limited country-specific analyses that
and distribution of personal protective equipment estimate the cost of treating COVID-19 cases from
(PPEs), discouraging non-essential travel into Ghana, health systems perspective in Africa. One Kenyan ana-
temporarily suspending all foreign travels for public offi- lysis estimated the cost of treating COVID-19 patients
cials and mobilizing $US100 million towards implemen- to range from US$282 in home management to
tation of the country’s preparedness and response US$5707 in critical care settings [19]. In another attempt
strategy [7–10]. When Ghana recorded its first case of to estimate the probable cost of the entire response to
COVID-19 on 12th March 2020, it initiated an aggres- COVID-19, Rueda et al. extrapolated data from costing
sive contact tracing program leading to the detection of of other diseases in South Africa, Ethiopia, and Pakistan
132 cases before the end of March 2020 [10, 11] and to low-and-middle-income countries. The authors esti-
community spread had been established across all 16 ad- mated the cost of treatment to be between US$147 in
ministrative regions before end of June 2020, but major- home-based management and US$1082 per day for crit-
ity of cases remained in the two most urbanised regions ically ill patients managed in resource-intensive settings
(Greater Accra and Ashanti). The case count increased [20]. However, as the characteristics of the pandemic
dramatically to 45,655 by mid-September 2020 although evolved, so did the global strategies, which ultimately
mortality rate remained markedly lower than 1% [12]. In impacted on the case management and overall response
Ismaila et al. BMC Health Services Research (2021) 21:1115 Page 3 of 10

of countries. The wide variations in case management institutionalised care) which culminated in the develop-
protocols between countries have made it even impera- ment of resource use identification template. The resource
tive for context-specific estimation of the cost of treat- template was used to collect data, with the assistance of
ment as part of the needed evidence towards the frontline clinicians, on the resources used to treat each
adoption of sustainable policies and priorities on type of patient (by the level of disease severity and treat-
COVID-19 interventions. The context-specific evidence ment setting), and the quantity of the resources used. The
gap in the cost of treating COVID-19 patients tend to identified resource use with quantities was validated by
slow down rapid resource planning, hence the analysis two of the country’s leading experts in COVID-19 case
sought to fill the gap in the context of Ghana but could management and further reviewed by the case manage-
be replicated in other settings. ment Team Lead of the West African Health Organisation
We adopt a health system’s perspective and a bottom- (WAHO). The resource use was categorised into five [5]:
up, point of care resource use data collection approach overheads (patient accommodation, utilities, feeding and
to estimate the protocol-based cost of clinical manage- toiletries, as well as set of personal protective equipment
ment of COVID-19 infection in Ghana. used by the health professionals), investigations, medica-
tions, in-patient care and human resources (staff time). In
Methods the case of home isolated patients, we considered costs re-
We employed a costing approach guided by the costing lating to provided items (thermometer, cost of visits and
framework proposed by Drummond [21] and based on staff time). Ghana’s treatment protocol for COVID-19
the approved national COVID-19 treatment protocol for specified that all moderate, severe or critically ill patients
Ghana (see summary in Figs. 1 and 2) [6]. We adopted a be treated in hospitals while those with no or mild symp-
bottom-up, point of care resource use data collection ap- toms are supported to manage at home or at isolation
proach. Resource use for each type of patient (according centres where the home environment is deemed incondu-
to disease severity) was identified and quantified using the cive for isolation.
case management protocol in use as of September 2020
and with the advice of clinical experts in the frontlines of Resource use and cost drivers by the level of severity
protocols development and COVID-19 treatment in the Patients that received institutionalised care at isolation
country. No patients were enrolled into the study and centres or hospitals were transported from their homes
hence, no patient characteristics were analysed or de- or point of referral to the treatment centre or hospital
scribed. However, protocol-based cost analyses have a and sent back upon discharge. This was an essential part
good place in planning and resource mobilisation, as well of the overhead cost alongside patient accommodation,
as guiding updates and implementation of the protocol as feeding and toiletries, as well as set of personal protect-
they make available resource use implications to clinicians ive equipment used by the health professionals. The re-
and policy makers. It is in this light that this paper sought source need differentials in the overhead category were
to adopt a protocol-based analysis when enrolling driven by the average length of stay, which was for up to
COVID-19 patients was ethically not permissible at the 21 days for severely or critically ill patients and 19 days
time. The protocol-based cost analysis was conducted be- for the rest. Home managed patients received a therm-
tween August and September 2020. ometer for self-monitoring and were paid visits by clini-
cians (staff time) which formed the overhead costs from
The perspective of cost the health system perspective.
The Ministry of Health fully bore the cost of COVID-19 Resources needed for investigations and monitoring of
treatment; hence the Ministry’s perspective of the cost patient prognosis included materials for sample taking
was adopted for this analysis. Costs related to loss of in- and reagents like test kits for SARS-COV-2 test, full
come to patients were not considered, as were those blood count, blood gases, chemistries, and coagulation
losts of revenue to health facilities due to reduced profile. Other investigative procedures included x-rays,
utilization of other routine services arising from the sus- computer tomography (CT) scans, electrocardiogram
pension of such services or patients not demanding for (ECG) and ultrasound scans for pregnant women. The
them for fear of the COVID-19 pandemic. resources needed for, and frequency of, these investiga-
tions varied markedly depending on the severity of the
Resource use identification and quantification per patient disease. For instance, while all these were necessary for
by the level of severity critically ill patients, analysing blood gases were not indi-
The COVID-19 treatment protocol of Ghana as of Sep- cated for those classified as severe unless they were put
tember 2020 was reviewed together with clinicians to on a ventilator (where oxygen saturation was less than
identify resource use elements for the different levels of 90% with a continuous downward trend despite optimal
disease severity and setting of treatment (home or oxygenation or when significant lung changes were
Ismaila et al. BMC Health Services Research (2021) 21:1115 Page 4 of 10

Fig. 1 Clinical management protocol in use as of September 2020. Source: Ministry of Health. COVID-19 management guidelines

detected on x-ray or CT scan). Similarly, blood gases, azithromycin for all patients regardless of the treatment
CT-Scan, chemistries, ECG and coagulation profile were settings. Patients with severe illness or those who re-
not included in the monitoring protocol for those with quired high dependency or intensive care received add-
mild illness or those that were asymptomatic. For pa- itional antibiotics such as ceftriaxone and thrombolytics
tients managed at home, only routine temperature (commonly enoxaparin).
checking, and the SARS-COV-2 test were needed. Resources needed to facilitate the in-patient care of all
Another category of resource use was medications, institutionally managed patients included oxygen for pa-
which the treatment protocol outlined the use of vitamin tients who experienced difficulty in breathing, and
C with zinc, hydroxychloroquine (or chloroquine) and mechanical ventilation for critically ill patients, patients
Ismaila et al. BMC Health Services Research (2021) 21:1115 Page 5 of 10

Fig. 2 Specific guide on medicines to be used. Source: Ministry of Health. COVID-19 management guidelines

with severe symptoms and oxygen saturation of 90% or nurses’ time per day – of various skill-mix. Additional
less, as well as for in-patients with significant lung file 1: Supplementary appendix 1 provides details of
changes on x-ray or CT scan. The use of oxygen and the resource needs identified for each level of the dis-
mechanical ventilation was concomitantly associated ease severity and the associated unit cost. The rest of
with the use of syringes, needles, oxygen masks, endo- the analysis was based on these resource use and unit
tracheal tubes, among others. costs.
The health workforce needed for the management of
each case depended on the level of severity and availabil- Assigning unit cost for each unit of resources used
ity of other resources. For example, severely ill patients The unit cost of the resources used in treating
required up to 4 h of medical specialists’ time and 6 h of COVID-19 patients was triangulated from Ghana’s
Ismaila et al. BMC Health Services Research (2021) 21:1115 Page 6 of 10

National Health Insurance Scheme (NHIS) price list Result

for medicines and services [22, 23], average prices Average cost of treatment per COVID-19 case – by level
from the Public Procurement Authority [24], the of disease severity
Government salary structure for public sector health The cost of treating COVID-19 patients in Ghana irre-
workers [25] and invoices of procured goods that spective of the setting and level of severity from the per-
were that hitherto were not regularly procured (ex- spective of the health system ranged from US$282 (GH
ample Personal Protective Equipment, PPEs). Where ¢1629) to US$23,382 (GH ¢135,149), with an average of
the unit costs could not be obtained from these US$11,925 (GH ¢68,929). For patients that were treated
sources, local open market prices were used except in hospitals or treatment centres, the overhead cost, not-
for resources that were not on sale in the local mar- ably for PPEs and Transportation, were the main cost
ket where the international prices were adopted. drivers, followed by the cost of in-patient care (see
Table 1 for cost summary in USD and supplementary
Tables S1 – S5 for resource use and unit cost in local
Cost estimation per patient tenement currency unit, the Ghana Cedis). For home management,
Using the resources identified and quantified for each the main cost drivers were investigations (COVID-19
patient type, and the unit cost, the cost of treatment per testing) and staff time. As shown in Table 2, overhead
patient (by the level of severity) was computed using the cost on average accounted for 55% (6–71%) of the cost
following formula: of clinical management COVID-19 cases in Ghana,
followed by in-patient care which accounted for 19%
(17–22%). Across all cases, the third cost driver was staff
TotalX
cost of treatment for patient i
  time, accounting for 18% (4–42%) of the treatment cost,
¼ j
Resourceij x Unit cost j followed by investigations which accounted for 11% (1–
47%) of the total cost. Interestingly, medications consti-
tuted only 2% (0.02–5%).
Where:
It is worth noting that there was a wide range in the
proportion of cost attributable to overheads, staff time
 Resourceij is the amount of resource j used by
and investigations. For example, there was a 65% cost
patients with disease severity i
differential between the overhead cost of patients man-
 Unit costj is the unit cost for resource j
aged at home and those managed in institutional set-
tings; and across the different levels of disease severity of
We compared the cost of treatment by the differ-
those that were institutionally managed. Eighty one per-
ent categories of resource use within the same level
cent (81%) of the overhead costs for institutionally-
of disease severity and across the different levels of
managed patients were attributable to PPEs, 28% for ac-
disease severity as well as treatments settings –
commodation and utilities, and 3% for transportation.
home-based care or institutionalised care. The
To put this in perspective, critically ill patients who
estimated costs were not discounted or adjusted for
spent about 21 days in hospitals consumed up to 210
inflation since they were cross-sectional with no
sets of PPEs for the duration of their stay as compared
long-term extrapolation. The official exchange rate
to 38 sets of PPEs consumed by patients with mild
of 5.78 Ghana Cedis to US$1 (as of end of August)
symptoms with an average length of stay of 19 days.
was used for converting the cost from the local
Similarly, several investigations (and repeat investiga-
currency (Ghana Cedis) to the United States Dollar.
tions) were required for patients with increasing levels of

Table 1 Estimated cost of COVID-19 treatment by the level of severity and treatment setting (in United States Dollars, USD)
Cost Cost of home Estimated cost by level of disease severity for institutionalised care (USD) Average
Category management
Mild Moderate Severe Critical
(USD)
In-patient care – 1259 1269 3546 4587 4066
Investigations 132 147 340 277 489 277
Medications 14 14 89 199 335 130
Overheads 17 4072 6701 13,276 14,660 7745
Staff time 118 215 1552 3007 3312 1641
Total 282 5707 9952 20,305 23,382 11,925
Note: the analysis presented in the table was based on the COVID-19 treatment protocol. No patient data is reported in this table
Ismaila et al. BMC Health Services Research (2021) 21:1115 Page 7 of 10

Table 2 Proportional cost distribution by cost category, level of severity and treatment setting
Cost Category Home Level of Disease Severity for Institutionalised Care
management
Mild Moderate Severe Critical
In-patient care 0% 22% 13% 17% 20%
Investigations 47% 3% 3% 1% 2%
Medications 5% 0.2% 1% 1% 1%
Overheads 6% 71% 67% 65% 63%
Staff time 42% 4% 16% 15% 14%
Total 100% 100% 100% 100% 100%
Cost difference (US$) 5425 4245 10,353 3078
% Increase disease severity to another 1925.2% 74.4% 104.0% 15.2%
Note: the analysis presented in the table was based on the COVID-19 treatment protocol. No patient data is reported in this table

severity, thereby accounting for 46% in the cost variation deteriorating from moderate to severe resulted in about
observed for investigations. Also, as level of severity in- US$10,353 (104%) additional cost, and a relatively mar-
creased, the expertise and number of health workforce ginal increase of 15.2% (US$3,078 or GH ¢17,788) be-
(staff time) needed to address the patient health problem tween patients with severe symptoms and those that
increased, hence a US$10,588 difference between the were critically ill. Deterioration from mild to moderate
staffing costs of treating mild and critically ill patients. required US$4,245 (GH ¢24,536) worth of additional re-
This represents a 186% difference in the staffing costs source, representing a 74.4% increase in the cost of
between the extremes of the disease when managed in treatment.
institutional settings.
Discussion
Cost differences in various levels of disease severity and Our analysis estimates that the average cost of treating a
treatment settings person infected with SARS-COV-2 in Ghana was about
Ghana’s case management protocol for COVID-19 US$11,925 (GH¢68,929), which ranged widely from
allowed for patients without obvious symptoms and US$282 (GH¢1629) for mild cases managed in home set-
those with mild symptoms to be managed at home, if in tings to US$23,382 (GH¢135,149) for critically ill pa-
the assessment of the clinician, the conditions necessary tients managed in resource intensive and specialised
for effective management at home were met. These cases hospital settings. Thus, the cost of treatment of COVID-
required fewer resources classified in the overhead’s cat- 19 could increase by at least 20-folds once a patient’s
egory, fewer clinical investigations, health workforce ex- condition warranted to be moved from home manage-
pertise and medications. ment to any type of hospital setting or institutionalised
Once a patient moved from home management to the treatment centre.
treatment centre, the cost of treatment increased by at There are limited number of publicly available works
least 20 folds. The criteria for managing a COVID-19 estimating the cost of COVID-19 response, including
patient in a treatment centre/hospital included mild and that of case management which is the thrust of this
asymptomatic cases whose home environment were paper. In one multi-country study underpinned by ex-
evaluated to be unconducive for effective treatment. trapolation of data from South Africa, Ethiopia and
These patients were usually kept in COVID-19 isolation/ Pakistan, the cost of managing COVID-19 cases was es-
treatment centres or specially designated areas in hospi- timated to range from US$147 per patient in home man-
tals. Additionally, all moderate, severe and critically ill agement to as high as US$1082 per case per day for
patients were managed in hospitals with the appropriate critically ill [20]. For home management, our estimate
capacities to address their health needs. The cost of was, however, 92% higher than that of South Africa (for
managing a patient with mild symptoms in isolation/ home-based management of non-symptomatic or mildly
treatment centre was estimated to be US$5707 (GH ¢ ill patients) as reported in the work of Rueda et al. The
32,985), with overheads accounting for about 71% of this difference between the two studies was even much
cost whiles in-patient care and staff time accounted for higher for severe cases where our estimate was ten times
22% and 4% respectively. higher. However, estimates of the two studies converged
The cost of treating patients with severe symptoms with a difference of less than 3% for the cost of treating
and the critically ill was about US$20,305 (GH ¢117,361) critically ill patients (US$1113 per day estimated in the
and US$23,382 (GH ¢135,149), respectively. Thus, current study versus US$1082 per day in the previous
Ismaila et al. BMC Health Services Research (2021) 21:1115 Page 8 of 10

study). Whereas we adopted a bottom-up, point of care to be the major cost driver, accounting for 45.1%, of the
resource use data collection approach, Rueda and col- overall mean [17].
leagues were unable to collect primary cost data directly From a cost containment perspective, these findings
from COVID-19 service delivery points, hence approxi- underline the need for early detection and effective
mated resource use and unit costs from previous works treatment of COVID-19 cases, preferably at home, be-
around tuberculosis (TB) or general health services. fore any chance of deterioration to the next worst
Thus, the difference in methodological approaches may form of the disease state. This is supported by our
have contributed to the differences in cost, in addition finding that the cost of treatment could increase by
to the contextual and treatment protocol differences that at least 20 folds once a patient moved from home
may exist between Ghana (where the present study was management to any type of institutionalised treatment
based) and South Africa, Ethiopia and Pakistan (whose centre (or hospital), most of which was related to
contexts were the basis of the previous work). overhead costs. For example, (as shown in Table 2),
In a Kenyan study, Barasa et al. estimated the cost of overhead cost accounted for 63–71% of the cost of
treating COVID-19 cases in Kenya as ranging from treating in hospitals and treatment centres as com-
US$278 per asymptomatic or mildly ill patient in home pared to 6% for those managed at home. The few
management to US$5879 per critically ill patient man- studies that have reported on the cost of treating
aged in resource-intense settings [19]; drawing close COVID-19 also collaborate these findings in the con-
similarities with current estimates from Ghana’s context text of Kenya, and broadly low-and middle-income
for home-based management (US$282 for Ghana versus countries. Nevertheless, the substantial cost jumps
US$278 for Kenya). However, the estimated cost of also raise concerns if there was still room for effi-
treating critically COVID-19 patients in Ghana was ciency gains in the resource use in the management
more than four times higher than Kenya - a difference of severe and critically ill patients that may accrue as
that could be attributed to, among other things, an aver- better evidence on the management of COVID-19
age of twelve days length of stay assumed in the Kenyan evolved.
study as compared to twenty-one days in the case of Protocol-based cost of illness analysis has potential
Ghana. utility in resource planning and mobilisation in respond-
Our study showed that once a patient moved from ing to the pandemic and also contributing to cost effect-
home management to the treatment centre, the average iveness evaluation of the treatment protocol. The results
cost of treatment increased by about 20-folds (US$282 of this analysis were made available to government and
to US$5707). A similar costing study found that, in the other partners through the national COVID-19 response
context of Kenya, home-based care for COVID-19 cases team to be used as part of context specific evidence as in
was nine times cheaper than institutional base care sce- the planning and resource mobilisation in the context of
narios with overheads, staff costs and PPEs being the COVID-19 response. However, at the time of preparing
drivers of the costs difference. the manuscript it was still premature to estimate to esti-
Meanwhile, the present study found that once a pa- mate the overall impact or contribution of this work to
tient’s condition deteriorated from mild to moderate, the the national COVID-19 response in Ghana. Neverthe-
cost escalated by 155% but the cost-mix shifted from less, as this work represents the first attempt at estimat-
71% overheads in the case of patients with mild symp- ing the cost of managing COVID-19 infections in
toms to 50% for cases with moderate symptoms, while Ghana, its potential utility cannot be overstated.
the cost of in-patient care increased from 22 to 35%.
Similarly, deteriorating from moderate to severe resulted Conclusion
in more than doubling the costs of treatment but only a From a health system perspective of cost, the clinical
marginal difference of 15.2% was found between the cost management of a COVID-19 patient in Ghana is aver-
of patients with severe symptoms versus those that were agely US$11,925 (GH¢68,929) but ranges widely from
critically ill. US$282 (GH¢1629) for mild/asymptomatic cases who
The current study also estimates that in institutionally are managed at home to as much as US$23,382 (GH¢
managed patients, overhead cost accounted for 63 to 135,149) for critically ill patients managed in resource
71% of the overall cost of treatment of which 81% were intensive hospital settings. It demonstrates that the cost
attributable to PPEs, 28% for accommodation and util- of treatment is at least 20 times higher in hospital set-
ities, and 3% for transportation. The cost of drugs tings or any type of institutionalised treatment centres
accounted for just up to 1% in institutionally managed as compared to home-based management. Therefore,
patients and 5% for patients managed at home. These cost savings could be made by early detection and effect-
findings, however, contrasted sharply with those of the ive treatment of COVID-19 cases, preferably at home,
Chinese study in which the cost of drugs was observed before any chance of deterioration to the next worst
Ismaila et al. BMC Health Services Research (2021) 21:1115 Page 9 of 10

form of the disease state, thereby freeing up more re- cases in Ghana and Africa. The results of this study, al-
sources for other aspects of the fight against the pan- though imprecise, provide a reasonable basis for estimat-
demic. Policy makers in Ghana should thus make it a ing the overall cost of the response and for planning
top priority to intensify the early detection and case resource needs for fighting the ongoing COVID-19 pan-
management of COVID-19 infections. demic in Ghana and other similar contexts.
Abbreviation
Limitations WHO: World Health Organization
This study has some inherent limitations that must be
considered when using the same for policy or decision Supplementary Information
making. First, it is worth noting that the estimates re- The online version contains supplementary material available at https://doi.
ported in this paper are based on Ghana’s COVID-19 org/10.1186/s12913-021-07101-z.
Case Management Protocol up to September 2020, after
which there might have been some changes, which Additional file 1. Table S1. Resource Use and Unit Costs for Critically ill
cases of COVID-19. Table S2. Resource Use and Unit Costs for Severe
would likely impact the results if the estimates were to Cases of COVID-19. Table S3. Resource Use and Unit Costs for Moderate
be updated in line with the new protocols. The type of Cases of COVID-19. Table S4. Resource Use and Unit Costs for Mild/
treatment required for COVID-19 as defined in the na- Asymptomatic Cases of COVID-19 (at hospitals or isolation centers). Table
S5. Resource Use and Unit Costs for home-based management of mild/
tional treatment protocol at the time of data collection asymptomatic cases.
provided no alternative pathways that could be used for
sensitivity analysis. Moreover, the cost data was taken Acknowledgements
from either procurement invoices at the Ministry of We express our gratitude to Clinical Care team of the Ga East Municipal
Hospital for their contribution to the data collection.
Health or the national health insurance reimbursement
price list, which also provided no plausible ranges for Authors’ contributions
sensitivity analysis. Under the circumstances, sensitivity HI and JAA are co-first authors. HI and JAA conceived the study and de-
analysis was not undertaken in this study which should signed the tools for data collection. JAA develop the model for analysis in
Microsoft excel. HI and EOM collected the data. SKA, VKL, EOM and JNO vali-
be considered a limitation. dated the data. HI, JAA and JNO led the initial drafting of the manuscript
Second, the costs of treating COVID-19 cases could with substantial contribution from SKA, VKL and EOM. All authors reviewed
vary drastically from the time the data was collected and approved the final manuscript. JNO and SKA oversaw the overall quality
assurance of the analysis and manuscript.
in June 2020 given the emergence of new variants
and deployment of vaccinations, both of which were Funding
not available in Ghana at the time of the analysis. Al- This work did not receive funding.
though, there has not been a major shift in Ghana’s Availability of data and materials
approach to COVID-19 case management, the gaps The datasets supporting our conclusions are publicly available and will be
identified must be considered as a limitation of this provided upon request to the corresponding author.
work, hence future update of this analysis with real- Declarations
life data that accounts for the impact of variants and
vaccinations would be imperative. Furthermore, the Ethics approval and consent to participate
The work is based on publicly available data and did not involve the use of
use of drugs, technology, and better risk stratification human subjects or animals. No ethical approval was required.
of patients would likely impact future resource con-
sumption by COVID-19 patients. Based on this, there Consent for publication
Not applicable.
is a need to continually update the estimation of the
costs of COVID-19 case management as the evidence Competing interests
and treatment protocols evolve. The authors declare that they have no competing interests.
Finally, although every effort was made to use the pre-
Author details
vailing market prices as unit costs for resources needed 1
Ghana Health Service, Headquarters Office, Private Mail Bag, Ministries,
for COVID-19 treatment, volatile pricing resulting from Accra, Ghana. 2World Health Organisation, Regional Office for Africa, UHC Life
the COVID-19 itself is one factor that could make these Course Cluster, Intercountry Support Team for Eastern and Southern Africa,
Zimbabwe, South Africa. 3ECOWAS Regional Centre for Disease Surveillance
estimates quickly outdated. Also, hydroxychloroquine and Control, Abuja, Nigeria. 4Ghana Health Service, Ga East Municipal
which was part of the treatment protocol was not avail- Hospital, Accra, Ghana.
able on the local market; hence its price was taken from
Received: 28 December 2020 Accepted: 30 September 2021
international sources.
Nevertheless, this study, to the best of our knowledge,
represents one of the first attempts to undertake References
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