CHAPTER ONE
INTRODUCTION
Background to the Study
Cancer is the second leading cause of death and disability in the world followed by heart disease (Mathers & Lancer, 2006). It is a major public health issue and represents a significant burden of disease. Based on the most complete and current data available, cancer accounts for one out of every eight deaths annually (Mathers & Lancer, 2006). The incidence and death rates from cancer remain significantly higher in the developing world including Nigeria (Boyle & Levin, 2008). It is responsible for more deaths than all the deaths due to HIV/AIDS, TB and malaria combined (Okoye, 2010). Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells (Global cancer facts and figures, 2011). It affects different parts of the body and the name of the cancer is given in relation to the part that is affected. It is a global disease that consumes resources. The cost of cancer treatment globally is reported to be high. Records have it that developed countries spend more on cancer treatment than developing countries; for example in the United States of America, the economic burden from cancer is tagged at $895 billion nearly 20% more than heart diseases toll ($753 billion) (John & Ross, 2009). The cancers which account for the largest costs on a global scale, and the greatest burden in developed nations are; lung, colorectal and breast while in low-income countries, the cancer with the greatest impact are cancer of the mouth and oropharynx, cancer of the cervix, breast and prostate cancer (John & Rose, 2009). According to John & Ross (2009) in Economist Intelligence Unit, WHO in 2002 reported that, in developing countries especially Sub-Saharan Africa, cancer control including prevention and detection is much less established with evidence showing that, only 5% of global resources for cancer are spent in the developing world. Owing to the fact that cancers are not detected in the early stages, when many are more easily treatable, treatment is less effective. In developing countries, 80% of patients with cancer progress to incurable stages (Kanavas, 2006). The specific economic challenges relating to cancer control in the developing world are exacerbated by other related phenomena; which include inadequate health systems infrastructure, scarcity of specialized skills (and specialists), high diagnostic and treatment costs, and the resulting inability to provide lengthy, complex personalised treatment regimens and follow-up care as necessary (Axios, 2009). Some of these challenges are caused at least in part by inadequate funding thereby leaving patients, relations and care givers to bear the cost of diagnosis and treatment. Globally, Africa has the least amount of funds voted for cancer management. For instance, Africa with a population of 1,007,766 cancer patients spends $849m while America with a population of 889, 640 cancer cases spends $153,941m (Beaulieu, Bloom, Bloom, 2009).In Nigeria, cost of cancer diagnosis and treatment is borne out of pocket. Out of pocket spending, (OOPS) is the major payment mechanism for health care in Nigeria and this can lead to catastrophic spending especially for the poorest households (Onwuasigwe, 2010). Adebamowo (2007) observed that, clinical services for cancer are grossly inadequate and poorly distributed. Only few centres have functioning radiotherapy equipment. Radiological examinations are generally available; however, access is limited by cost. He further stated that, although chemotherapy is available, high cost prevents most patients from taking advantage of modern regimens. Adewale (2011) commenting in Nigeria health journal opined that, the problem for a poor Nigerian could actually begin with these tests as they are not only done in few centres but can also be quite expensive. Cost is the major reason for non adherence to cancer screening and treatment for the people of low socioeconomic status (Adewale, Lawan & Adesunkani, 2008).When the economic status of the patient is inadequate to meet with the cost of screening and treatment, they look for other payment coping mechanism. Payment coping mechanisms was short term strategy used to cope with the cost of medical care (Adams & Ke, 2008). Payment coping mechanism consists of non-income financing of healthcare; savings, borrowing and selling of assets (WHO, 2008). Although the Nigerian government provides exemption for treatment of malaria in under 5s and pregnant women, there is no exemption for cancer patients; a growing epidemic with largely increasing healthcare cost, especially with its late diagnosis. Cancer like many other known communicable diseases, have not entered the government policy agenda and as such, is not yet integrated into the primary health care system as resolved by the World Health Assembly in 2002. All these reflect the economic burden and inability of most patients to cope with the costs of screening tests and treatment of cancer.
Statement of Problem
There is dearth of evidence on the cost of cancer treatment and the distribution of costs among various socioeconomic groups affected by cancer (World Bank, 2006). In Nigeria, the health insurance coverage is still very low (5%) and cancer treatment is not in the benefit package and there are no form of exemptions. For someone with cancer, the common means of payment for treatment are direct out of pocket payments. Out of pocket payments have been shown to have impoverishing effects on households (World Bank, 2006). This is further compounded by the fact that 60-70% of Nigerians live below poverty line of 1 dollar per day (Merie-Nelly, 2013). Little is known about the economic burden of cancer considering different socio-economic groups in Nigeria and their payment coping mechanism. In Jos University Teaching Hospital (JUTH), about 9 patients have had to sign against medical advice within 7 months as a result of their inability to cope with the cost of their investigations/treatment. Some of the patients are only able to take the 1st phase of chemotherapy while subsequent phases are forgone. JUTH is a major centre in Plateau State, with facilities for screening and treatment. One would expect a reduction in the number of people attending the oncology clinic but this is not the case. Given the incidence of cancer and the national government decision to address cancer, a study of how households are affected by cancer will aid in the formulation of policies that may help to prevent households from being pushed into poverty. Therefore, this study was undertaken to determine the economic burden and payment coping mechanism of households affected by cancer.
Purpose of the Study
The purpose of this study was to determine the economic burden of cancer and payment coping mechanism among cancer patients receiving treatment in Jos University Teaching Hospital (JUTH), Plateau State.
Specific objectives
The objectives of this study were to:1. Determine the direct medical cost of cancer incurred by patients and their households in JUTH.2. Assess the indirect medical cost of cancer incurred by patients and their households in JUTH.3. Estimate the cost distribution among different socio-economic groups.4. Identify the payment coping mechanism utilized by different socio-economic groups.
Research Questions
1. What are the direct medical costs incurred by cancer patients and their households in JUTH?2. What are the indirect medical cost of cancer incurred by patients and their households in JUTH?3. What is the cost distribution among different socio-economic groups?4. What is the payment coping mechanism utilized by different socio-economic groups?
Research Hypotheses
1. There will be no significant difference in the cost distribution of cancer treatment among different socio-economic groups.2. There will be no significant difference in the payment coping mechanisms between different socio-economic groups.
Significance of the Study
It will assist cancer societies in making a case towards the inclusion of cancer management in the National Health Insurance Scheme considering the economic burden of its management. The findings of this study will help to reveal the direct and indirect costs of treatment borne by cancer patients. The findings will serve as a tool to advocate for the inclusion of cancer care into the National Policy Agenda and to source for support from both governmental and non-governmental bodies towards the management of cancer. It will provide a better understanding of the economic impact of the disease and challenge to health care providers towards rendering qualitative costeffective care that will shorten the stay of patients in the hospital: and reduce the frequency of visits to the health care facility thereby reducing cost of health care of cancer patients. The findings will assist policy makers and other stake holders in decision making, particularly towards resource allocation and research funding