Economic Burden Of Cancer And Payment Coping Mechanism
The economic burden of cancer and the stress of payment require that, health care providers provide quality cost-effective care that will shorten the stay of patients in the hospital and reduce the frequency of visit to health facilities. This study investigated the economic burden of cancer patients and payment coping mechanism in Jos University Teaching Hospital, Plateau State. Four objectives and two hypotheses were raised to guide the study. Cost-of-illness framework was used to assess the economic burden of cancer patients and payment coping mechanism. A cross-sectional descriptive survey design was used for the study.
A sample of 179 cancer patients was drawn consecutively from an estimated population of 276 that used the hospital in one year. Data were analyzed descriptively using frequencies, percentages, mean and standard deviation. Chi-square was used to determine the association between socio-economic groups and payment coping mechanisms utilized by cancer patients and between the cost distributions among different socio-economic groups. Majority of respondents were ranked among the poorest, the mean monthly total income of the patients is N65,978.74 + 104,036.97, mean monthly total expenses is N43,916.28 + 56,070.33, the mean monthly patients’ expenditure is N43,916.28 + 56,070.33, the mean total annual loss was N217,515.19 + 798,708.95, the mean patients’ annual loss as a percentage of their mean annual income is 11.38 + 19.13% while as a percentage of their mean annual expenditure was 50.06 + 421.98.
There was a significant difference in the cost distribution of different socio-economic groups in terms of monthly patients’ total income, monthly earnings of persons accompanying patients, patients’ monthly loss, accompanying persons’ monthly loss, total monthly loss, patients’ annual loss, accompanying persons’ annual loss and total annual loss (P < 0.05). Payment coping mechanism utilized by most (78.8%) of the patients was their own money (i.e. salary, earnings and/or savings). There was a significant difference between payment coping mechanism of cancer patients (borrowed money/loan, sales of land) and different socio-economic groups (P < 0.05). There is need for government to intervene by subsidizing the cost of cancer treatment. There is need for the formation of a strong cancer Association in Plateau State so that cancer patients could pool their resources together as a strong social support to help themselves.
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.
The objectives of this study were to:
- Determine the direct medical cost of cancer incurred by patients and their households in JUTH.
- Assess the indirect medical cost of cancer incurred by patients and their households in JUTH.
- Estimate the cost distribution among different socio-economic groups.
- Identify the payment coping mechanism utilized by different socio-economic groups.
- What are the direct medical costs incurred by cancer patients and their households in JUTH?
- What are the indirect medical cost of cancer incurred by patients and their households in JUTH?
- What is the cost distribution among different socio-economic groups?
- What is the payment coping mechanism utilized by different socio-economic groups?
- There will be no significant difference in the cost distribution of cancer treatment among different socio-economic groups.
- 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 cost-effective 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.
Scope of the Study
The study was delimited to all those who had been diagnosed of cancer and have been receiving treatment from JUTH within the past one year. Both males and females within the ages of 18 years and above were studied. Out-patients and in-patients were studied. Medical-Surgical units, specialist clinics, and family medicine were used. Insignificant cost of cancer was not included in this study.
Operational Definition of Terms
Refers to both medical and non-medical costs incurred by cancer patients in the management of their ailment. It is classified into direct and indirect costs.
Direct Cost (Financial Cost):
This has to do with cost related to investigations, diagnoses, treatment, admissions, follow up costs and travel cost.
They are those things that will be forgone for the sake of this illness e.g. time spent travelling, waiting time in hospital, time spent out-of-work, time accompanying relative, time lost through premature death or premature retirement.
Payment Coping Mechanism:
Refers to the use of ones’ income (salary and savings), someone else paying, money borrowed/loans, community based support, sale of household assets, gifts, appeal for support/ begging, temporary stoppage of children’s education, cutting down on minimum consumption expenses to pay for treatment and tests.
Refers to someone who has been diagnosed by a physician as having cancer of any type.
Cancer Family/Significant Others:
This includes, parents, brothers, sisters, surrogate or friend who accompanies patient for treatment and have lived consistently with this experience for at least one year.
Different Socio-Economic Population Group:
This refers to the categorization of study patients into various levels or classes. This will be determined using asset ownership like Radio, Television, bicycle, air conditioner, electric fan, Motorcycle, Fridge, kerosene stove, generator, gas cooker and car on a socio-economic status index, type of food and living accommodation. Socio-economic population is also categorized into poorest, poorer and least poor.
Discussion of Findings, Conclusion and Recommendation
Discussion of Findings,
In this chapter, findings of the study were discussed. Report on the findings were done under: discussion of the major findings, implications of the findings, limitations of the study, suggestions for further studies, summary of the study, conclusions and recommendations.
Direct medical cost of cancer incurred by patients and their households.
The findings of this study revealed that the direct medical cost of cancer incurred by patients and their household was high, (mean N30,757.95 + 27,325.82). This high cost of managing cancer by the respondents was compounded by out of pocket payment (OOP) considered to be high for an average Nigerian. The findings agree with that of Walsh and Crumbie (2007) who observed that, when a patient is diagnosed with cancer, the financial resources of the family may be affected by the loss of ability to work and the needs of the family may be neglected. John and Ross, (2009) also align with the result of this study by stating that cancer consumes a lot of funds in the developed world where a reasonable percentage of their budget goes to health. Similarly, the findings conform with the assertion of Onwujekwu, Uzochukwu, ObikezeOkonkwo, Ochonwa, Onoka et al (2010) who opined that cancer patients in developing countries like Nigeria play a large share of the health care cost out of pocket (OOPs) due to lack of financial risk protection mechanisms. Cancer exerts a heavy financial economic burden on individuals, national and society at large. It affects quality of life, not only of the patient and their immediate families but also society. High medical cost seen in the treatment of cancer poses a barrier to seeking health care.
Indirect medical cost of cancer incurred by patients and their households.
Findings from this study showed that the indirect cost incurred by patients and their household were; time taken to see a doctor on days of appointment and time utilized by the patient to get to the hospital. Edelson (2007) supports the findings of this study by noting that patients spend long hours seeking and undergoing treatment. He observed that most patients spent an average of 99 hours getting care during illness, while others may spend about 488 and 512 hours of care respectively. Dorland, Hardecki, Hess, Memahan, (2014) observed that, waiting time for cancer patients appointment are sometimes long. This can be stressful. How long these patients wait depends on factors such as when the clients checked in with clerical staff and wait time can be driven by the numbers of patients in the clinic area at one time.
Cost distribution among different socio-economic groups.
Findings revealed that majority (79.3%) of the respondents were in the poorest group. They had a minimum income of 833.3 while the least poor were (5.0%) and they had a maximum income of 100,000.00. The findings of this study agree with the report of clegg et al (2010) who observed that men and women with less than a high school education had elevated lung cancer rate ratio of 3.01 and 2.02 respectively, relative to their college educated counterparts. Those with family annual income less than 12,500 U.S dollars had incidence rates that were more than 1.7 times the lung cancer incidence rate of those with income 50,000 U.S dollars or higher.
Similarly Rusell, (2004) and Akobundu (2006) supports the findings of this study by stating that, 40% expenditure on cancer care could be considered as catastrophic but considering socio-economic inequalities it would also assess catastrophic expenditure at 100% and 40% for the poorest socio-economic and the least poor socio-economic status group respectively. These authors also noted that socio-economic status of patients varied for specific cancer while such patterns for stage were generally consistent across cancers with latter state diagnosis being associated with lower SES. There is a disparity in cancer outcome according to a variety of individual socio-economic, demographic and health care characteristics, as well as by area measured available in the linked data base. This author also agreed with the findings of this study by nothing that those families with annual income less than 12,500 U.S dollars had incidence rates that were more than 1.7 times the lung cancer incidence rate of those with income 50,000 U.S dollars or higher.
The findings are also in line with Wright et al (2011) who reported in their study that racial and ethnic minorities, particularly those in impoverished urban communities, have higher colorectal cancer morbidity and mortality rates as a result of the cost of treatment, and there is lower rates of recommended colorectal cancer treatment among African American patients compared with their white counterparts.
The payment coping mechanisms utilized by different socio-economic groups
The findings of the study showed that the major coping mechanisms utilized by different socio-economic groups were; patients own money (salary, earnings, savings) and payment by family members. Most of the respondents have difficulty in paying for cancer treatment.
The findings conform with the assertion of Adams and Ke (2008) who found that very high health care expenditures relative to income in households may force house hold members to cut their consumption of other minimum needs. This triggers the use of payment coping mechanisms to cater for the costs of health care. Such strategies include selling of assets, borrowing , perceived cost, saving behaviours like skipping appointment, skipping doses of drugs to make it last longer or seeking and use of treatment from cheaper alternatives at the expense of good quality. In the same vein Omolawa, (2013) found in his work that the choice of a coping strategy differs in different context among households in the face of economic burden of illness and will depend on a house hold’s asset base. While such strategies may meet the short term goal of paying for treatment and minimizing costs, financing health care with payment coping mechanism leads to sacrificing of necessary consumptions to pay for health care thus, pushing the house hold into deeper poverty. The mechanisms include but not limited to the following, appeal for charity/begging, borrowing/loans, gifts, savings and cutting down on minimum consumptions.
Onwujekwe, (2010) agrees with the findings of this work by asserting that in Nigeria, the various coping mechanisms utilized by households in the treatment of cancer patients include distress scale of assets, reduced intake of food to conserve funds, interruption of children’s education, informal and formal borrowing, charitable support from churches, gifts from friends while on the same note, Oyekale and Yusuf (2010) support by including other coping mechanisms such installment payment, borrowing, reimbursement, off front payment and in kind payment. This is so because the treatment is expensive and payment is borne out of pocket (OOP) by the patients.
Implications of the Findings to Nursing Practice
- The economic burden of cancer patients in this study is very high for the patients. This would lead to increasing poverty and poor rate of development as the productive age group is mostly affected within this region. The disease will progress rapidly in the patients with attendant poor quality of life, increase morbidity, mortality and productivity loses.
- Medical technology is increasingly costly in most fields of clinical medicine. Oncology has not been spared from issues related to cost, in part resulting from the tremendous scientific progress that has led to new tools for diagnosis, treatment and follow up of patients. Nurses represent a critical link among patients, support groups and insurance companies. Thus, it is imperative for the nurse practitioner to understand the role and value of cancer therapies and help remove financial barriers for patients. An understanding of the basics of cost analysis is an essential tool in the struggle to impact health-care and policy change.
- The study identified payment coping mechanisms utilized by patients as patients own money and payment from family members. This could be burdensome for families. There is therefore the need for the nurse to provide guidance for the patient seeking available financial assistance. It is imperative to work in tandem with the social workers, case manager, to find financial support for medications. This may also include over all financial assistance to offset medical, living and transportation expenses.
- The nurse has the obligation to act as patients’ best advocate to seek individual funding where it can be found.
Based on the findings of this study, the following conclusions were made;
- The direct medical cost of cancer incurred by patients and their household was high.
- The indirect medical cost of cancer incurred by patients and their household were; time taken to see a doctor on days of appointment and time utilized by the patient to get to the hospital. It was concluded that, majority of the respondents were in the poorest group.
- The major coping mechanisms utilized by patients were; patients own money (salary, earnings savings) and payment by family members.
- There was a significant difference between socio-economic groups and payment strategies utilized by cancer patients.
- There was a significant difference in the cost distribution of different socio-economic groups.
- Cancer patients need financial assistance in order to cope with the cost of their treatment, since majority of them in this study are poor.
- There is need for government to intervene by subsidizing the cost of cancer treatment.
- There is need for the formation of strong cancer Association in Plateau State so that cancer patients could pool their resources together as a strong social support to help themselves.
- The cost of managing cancer is high. Nigeria Cancer Association should be aware of this so that advocacy for cancer patients could be made through appropriate channel for support.
- The government and None Governmental Associations need to be involved in cancer care.
- Research should be intensified to find cure for cancer thereby reducing the cost.
Limitation of the Study
It was difficult for the researcher to convince some of the cancer patients to participate in the study. Another constraint was the issue of industrial unrest prior to the time of data collection. This led to delay in data collection as some of the patients had not reported for follow up care.
Asset based information was observed to be sensitive to some respondents who felt they were audited. Few opted out of the study being angry with the government whom they said received their votes but failed to do so much towards alleviating their sufferings.
The technicality of the analysis of this work was time consuming and also capital intensive and distressing.
Suggestions for Further Studies
There is need to carry out more studies on the economic burden and payment coping mechanisms of cancer patients in other places different from this area of study.
The researcher also suggests that the National Assembly should legislate on the inclusion of cancer care in the National Health Insurance Scheme.
Summary of the Study
This work was carried out to determine the economic burden of cancer patients and payment coping mechanism in Jos University Teaching Hospital (JUTH), Plateau state. The study was designed to determine the;
- Direct medical cost of cancer incurred by patients and their households in JUTH.
- Indirect medical cost of cancer incurred by patients and their households in JUTH
- The cost distribution among different socio-economic groups
- The payment coping mechanism utilized by different socio-economic groups.
Literature was reviewed under conceptual, and empirical studies which were based under the objectives of the study. The research design was descriptive survey. Respondents were consecutively recruited, a sample size of 179 respondents who attended Jos University Teaching Hospital Plateau state was used for the study. A validated questionnaire was used to collect data, data obtained was subjected to descriptive and inferential statistics in form of chi-square test of association. Major findings of the study showed that the direct medical cost of cancer incurred by patients and their household was high (mean monthly cost = 30, 757. 97± 27, 325.82). the indirect medical cost incurred by patients and their household were; time taken to see a doctor on days of appointment and time utilized by the patient to get to the hospital. Majority (79.3%) of the respondents were in the poorest group, they had a minimum income of 833.3 while the least poor were (5.0%) and they had a minimum income of 100.000.00 . the major coping mechanisms utilized by different socio-economic group were, patients own money (salary, earnings, savings) and payment by family members. There is a significant difference between the socio-economic status and monthly patients total income (P = 0.00), monthly earnings of persons accompanying patients (P = 0.00), patients’ monthly loss (P = 0.018), accompanying persons’ monthly loss (P = 0.006), total monthly loss (P = 0.011), patients’ annual loss (P = 0.018), accompanying persons’ annual loss (P = 0.006) and total annual loss (P = 0.011) there is no significant difference in the socio-economic status of the patients and minutes taken to get to JUTH on appointment date (P = 0.409), time taken to see doctor on each appointment date (P = 0.556), days absent from work because of sickness within the last one month (P = 0.347) monthly patients’ total expenditure (P = 0.083), patients’ annual loss as percentage of annual income (P = 0.594) and patients’ annual loss as percentage of annual expenditure (P = 0.057).
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