EPIDEMIC OF RHEUMATIC HEART DISEASE (RHD): A COST-BENEFIT MODEL COMPARING INVESTMENT IN PRIMARY PREVENTION (PENICILLIN FOR STREP THROAT) VERSUS BUILDING SURGICAL CAPACITY FOR VALVE REPAIR/REPLACEMENT IN A SPECIFIC LMIC REGION

Abstract

Background: Rheumatic Heart Disease (RHD) remains one of the leading causes of preventable cardiovascular morbidity and mortality in low- and middle-income countries (LMICs), particularly within the Southern African Development Community (SADC). Policymakers face a critical resource-allocation dilemma: whether to prioritize investment in primary prevention through the treatment of Group A Streptococcal pharyngitis with penicillin or to invest in costly surgical infrastructure for valve repair and replacement. This project aimed to evaluate the economic and public health impact of these competing strategies and identify the most effective policy pathway for reducing the burden of RHD across the SADC region.

Methods and Materials: A regionally calibrated cost-benefit analysis was conducted using a Markov cohort model developed in Microsoft Excel with Visual Basic for Applications (VBA). The model simulated disease progression from streptococcal pharyngitis to acute rheumatic fever and advanced RHD over a 15-year horizon (2026–2040). Data were obtained through systematic literature review, national health accounts, SADC procurement databases, WHO datasets, and stakeholder consultations. Costs, disability-adjusted life years (DALYs), benefit-cost ratios (BCRs), and net present values (NPVs) were calculated for primary prevention, surgical intervention, and hybrid investment scenarios. Sensitivity and probabilistic analyses were performed to evaluate model robustness.

Results: Primary prevention demonstrated superior economic performance, generating a BCR of 6.2:1, a net present value of approximately $187 million, and an estimated 42,000 DALYs averted. In comparison, investment in surgical capacity alone yielded a BCR of 0.9:1, a negative net present value of approximately $23 million, and 8,500 DALYs averted. However, prevention-only strategies failed to address the existing backlog of approximately 85,000 patients with advanced RHD requiring surgical intervention. A phased hybrid strategy combining prevention scale-up with the establishment of a regional surgical center in Zambia achieved a BCR of 4.3:1 while reducing the surgical backlog by 85% over the study period. Sensitivity analyses confirmed the robustness of these findings across a wide range of epidemiological and economic assumptions.

Conclusion: Primary prevention of RHD through timely diagnosis and penicillin treatment represents the most cost-effective investment for SADC member states. Nevertheless, exclusive reliance on prevention raises significant ethical concerns due to the unmet needs of patients with advanced disease. A phased hybrid approach that prioritizes prevention while strategically expanding regional surgical capacity offers the optimal balance between economic efficiency, equity, and long-term population health improvement. The findings provide a practical framework for policymakers seeking sustainable solutions to reduce the burden of RHD in resource-constrained settings.