TABLE
OF CONTENTS
Title
page i
Approval
page ii
Certification
iii
Dedication
iv
Acknowledgement
v
Table
of contents vi
List
of tables vii
Abstract
viii
CHAPTER ONE: INTRODUCTION
Background
to the Study 1
Statement of the Problem 4
Purpose
of the Study 5
Objectives
of the Study 5
Research
Hypothesis 5
Significance
of the Study 6
Scope
of the Study 7
Operational Definition of Terms 7
CHAPTER TWO: LITERATURE REVIEW
Concept of Diabetes Mellitus 9
Types of Diabetes Mellitus 10
Risk Factors/causes of Diabetes 12
Diagnosis of Diabetes Mellitus 14
Management of Diabetes 17
Concept of Catastrophic Health Expenditure 22
Catastrophic Health Expenditure in Nigeria 29
Payment Strategies in Healthcare 30
Payment Coping Mechanism 37
Conceptual Framework for the Study 41
Empirical Review 45
Summary of reviewed Literature 56
CHAPTER 3: RESEARCH METHOD
Research
Design 58
Area
of Study 58
Target Population 59
Sample 59
Inclusion Criteria 60
Sampling Procedure 60
Instrument for Data Collection 60
Validity of Instrument 61
Reliability of the Instrument 62
Ethical Consideration 62
Procedure for Data Collection 62
Method of Data Analysis 63
CHAPTER FOUR: PRESENTAION OF RESULT
Summary of Findings 85
CHAPTER FIVE: DISCUSSION OF
FINDINGS
Discussion of Findings 87
Conclusion 101
Implication of the Findings 102
Recommendations 102
Summary 104
Limitations of the Study 106
Suggestions for further Studies 108
References 110
Appendices 119
Appendix I- The questionnaire 120
Appendix II- Ethical clearance 128
Appendix III- Patient informed consent form 129
LIST OF TABLE
Table 1: Demographic Characteristics of Respondents. 65
Table
2: Length of DM Treatment and Frequency
of checkup at FMC Umuahia. 66
Table 3: Direct Cost of DM per Month Reflecting Unit Costs. 67
Table 4: Sources of Income of Respondents. 68
Table
5: Respondent is Earning from income Source and their Earnings per hour 68
Table 6: Number of Days Respondents were Absent from work in a Month because of DM (Mean SD) 69
Table 7: Employment
status of person accompanying respondents to treatment venues 69
Table 8: Indirect cost of DM care. 70
Table 9: Respondents’ monthly expenditure in Naira and mean catastrophic DM cost at 40% threshold. 72
Table10: Household socioeconomic status of respondents. 73
Table 11: Respondents expenditure per month by socioeconomic status (SD) and Catastrophic expenditure 74
Table 12: Payment strategies used by respondents. 76
Table 13: Payment coping mechanisms used by respondents. 77
Table 14: The difference between SES and catastrophic DM expenditure 78
Table 15: The difference between socio-economic status of the respondents and the Payment strategies used. 80
Table16: The difference
between socioeconomic status of respondents and
Payment coping mechanism 82
Table 17: Respondents report of level of ease/difficulty experienced in payment for Diabetic management. 84
Table 18: Respondent’s suggestions on ways to be assisted to cope with DM treatment. 84
ABSTRACT
Diabetes is a
chronic life- long illness that affects the quality of life, requiring close
monitoring and control. Diabetics have high risk for high economic burden
(direct and indirect health costs) and catastrophic expenditure where
healthcare costs are paid out of pocket. This study determined the economic
burden and assessed the payment strategies and payment coping mechanisms of
type 2 diabetic patients attending Out- Patient Department of Federal Medical
Centre (FMC) Umuahia, Abia State, South East Zone, Nigeria, July, 2011 to June,
2012. Literature were reviewed global and in Nigeria using the Cost- of-
illness (COI) framework. Five objectives guided the study and three hypotheses
were tested at 0.05 level of significance using Chi-square statistics.
Cross-sectional descriptive survey design was used to study a sample of 308
diabetics selected from Population of 1224 type2 Diabetic patients managed at
FMC Umuahia. The instrument for data collection was the questionnaire.
Reliability of the instrument determined with Cronbach alpha method which
yielded a coefficient of 0.40, 0.80, 0.75 and 0.68 sections A- D
respectively. Data were analysed using
descriptive and inferential statistics and presented in frequencies,
percentages, means and standard deviation. The major findings were direct cost
of type 2 DM of ₦52,104.28 and indirect cost of ₦139,659.60. The mean monthly
catastrophic type 2 diabetic costs in this study were direct cost 20.35%,
indirect cost 54.55% and overall catastrophe of 37.45%. Diabetics from all
socio-economic status group suffered catastrophic expenditure at 40%, 30% and
10% non-food expenditure, but the poorest socioeconomic status group had the
highest incidence. At 40% threshold catastrophic
expenditure by socio economic status were 44.6%, 27.4%, 17.8% and 13.9% poorest
(q1) to the least poor (q4) respectively. At a variable threshold of 10% for
the poorest and 30% for the least poor the catastrophic costs were 83.8% and
36.1% respectively. Private funding (Out of Pocket spending and instalment
payment) were the major payment strategies used. The major payment coping
mechanisms used were own money (earmarked savings and earnings), behavioural
payment coping mechanisms (instalment purchase of drugs) and social support
(family and friends paid). There was
significant relationship between socio-economic status and catastrophic type 2
DM costs (p < 0.05). Social support (community based insurance), health
insurance and prepayment, disposal of assets, community based support and cost
saving/evading behaviours were significantly related to socio-economic status
of the respondents. It was concluded
that the economic burden of type 2 DM is high and that people living with type
2 DM pay using private funds and incur catastrophic expenditure. In order to
reduce catastrophic expenditure, policies that will make services free at the
point of delivery are advocated. This will reduce incidence of DM complication,
morbidity and mortality from type 2 DM as well as reduce productivity losses.
CHAPTER ONE
INTRODUCTION
Background to the Study
Diabetes mellitus (DM) is a group of chronic medical
condition in which the body metabolism is deranged either due to none or
insufficient production or the body does not properly respond to insulin; a
hormone produced by the beta cells of
islets of Langahans in the pancreas (Adebayo, 2009). Insulin enables cells to
absorb glucose in order to turn it to energy. DM interferes with the
intermediary metabolites as a result of absolute or relative deficiency of
Insulin, producing a persistent hyperglycaemic state. The persistent
hyperglycaemia demands intensive care thus increasing the cost of care.
Diabetes mellitus is a growing “epidemic and pandemic” (WHO, 2002; Adebayo,
2009). WHO, (2008) estimates that more than 180 million people worldwide have
diabetes in 2008 and in 2009, the prevalence rose to 246million. Globally,
285million people had DM in 2010, projected to double by 2030 (Bilikis, 2012).
A diabetes prevalence of 20.8million (7% of population) for Nigeria is
considered high (Kiriga and Barry 2008; Odeleye 2008) and Nigeria having the
largest prevalence of DM in African region in 2011 (International Diabetes
Federation IDF, 2012) is a concern.
Diabetes affects the quality of life of
individuals/families; having a 5-fold risk of cardio-vascular diseases and
3-fold of stroke. It is the third cause of death from disease and complications
(Ikheiemoje, 2006; Smeltzer, Bare, Hinkle & Cheever 2008) and the second of
the 4 killer Non communicable diseases (Sridhar, 2011). Diabetes affects all
socio-economic groups but the low income groups are more affected (Smeltzer, et
al. 2008). In Nigeria and other
Sub-Saharan Africancountries,the active productive age groups (30-45years) are
mostly affected (Azevedo & Allai, 2008; Obayendo, 2008). Type2 diabetes which used to be of adult onset is
occurring much earlier due to obesity and lifestyle changes. Studies have shown
that the earlier the onset of diabetes, the earlier the onset of complications
with consequent higher direct and indirect cost of care (economic burden)
(Ikhesiemoje, 2006; Smeltzer et al. 2008; Idemyor, 2010).
Economic impact of healthcare expenditure on
individuals challenged with illness especially where prepayment system is
absent is a growing concern (Xu, et al. 2007; Onoka, Onwujekwe, Hanson &
Uzochukwu, 2010). This could be worse for patients with Diabetes Mellitus, a
chronic metabolic disorder requiring life-long treatment. The medical costs for
diabetics are high because they visit the health facilities 2-3 times more than
non-diabetics (Chang & Javitt, 2000). Diabetic patients incur increasing
costs of care paid out of pocket and absents from work often (Zhang, et al.
2010) (indirect cost).
D.M exerts a heavy burden on individual and society
in terms of increasing healthcare costs. The burden borne depends on the
purchasing power of individuals, social insurance policies of the nation they
live (Zhang, et al 2010) and amount of care received (IDF, 2005). WHO, (2005)
postulated that where health care is funded privately, individuals lack ability
to pay and there is no mechanism to pool financial risk as in Nigeria,
catastrophic spending is high. Catastrophic Healthcare expenditure is very high
healthcare spending beyond which individuals begin to sacrifice consumption of
basic needs. It is equal to or in excess of 40% of non-subsistence income
consumption (WHO, 2005); that is income available after basic needs have been
met (non food expenditure) but countries could set their thresholds based on
their peculiarities. In Nigeria private funding is more than 90%. More than 70%
of the population live below $1 a day and prepayment mechanism for pooling risk
is lacking (Soyibo, 2004; WHO, 2005; UN Report 2006; Onwujekwe, et al.
2009). Diabetics in Nigeria have high
risk for catastrophic expenditure not only because they visit the health
facilities 2 to 3 times more than non diabetics but most times present late with complications,
pay out of pocket (OOPS) and healthcare cost is increasing. Excessive reliance on OOPS exacerbates the
already inequitable access to quality care and exposes households to the
financial risks of expensive illnesses like DM (Soyibo, 2004). High cost of
care force individuals to adopt payment coping mechanisms which are short term
strategies used to cope with the costs of healthcare (Adams & Ke,
2008). It has also been recognised that
financing healthcare with payment coping mechanism further increases the total
cost and generates ‘hidden’ poverty (Adams & Ke, 2008; Oyakale & Yusuf,
2010).
The economic importance,
complications and death tolls are compelling national governments to pay more
attention to the impacts of D.M (Azevedo & Allai, 2008; Cummings 2010;
Sridhar, 2011). Diabetes mellitus is one of the priority Non Communicable
Diseases(NCDs) discussed by the United Nations General Assembly, September,
2011, because of its recognised health, economic and development importance. Nigeria
lost to these, 4.5million in human resources in 2009 (Osotimehin, 2009), loses
about $400 million per annum in national income from premature death (WHO,
2010) and incurs direct costs of about $800 million annually (Chukwu, 2011)
posing a major challenge to the actualisation of sustainable development in the
21st century, especially in developing countries with consideration
to their rates of morbidity and mortality.
Although Nigerian government
provided exemption for treatment of malaria in under-5s and pregnant women
(Federal Ministry of Health, 2003), there is no exemption for diabetes; a
growing epidemic with largely increasing healthcare costs especially with its
late diagnosis in Nigeria and some other Sub Saharan African countries. The
problems of living with diabetes are most acutely experienced by patients and
their immediate families (Adams & Ke, 2010), who also provide 95% the care
(IDF Clinical guidelines Task Force, 2005). They experience the greatest impact
of lifestyle changes that directly affect their quality of life. Evidenced-
based data is needed to move D.M into the national health policy agenda for
targeted intervention. Unfortunately, there is paucity of data on the magnitude
of the economic burden borne by diabetic Patients, their payment strategies and
payment coping mechanisms in Nigeria. There is therefore need to ascertain the
economic burden borne by diabetic patients and payment coping mechanisms from
people who are experiencing the illness and incurring the costs (Willen &
Willkie, 2006). This study therefore investigated the economic burden, payment
strategies and payment coping mechanisms of diabetic patients attending a
tertiary health institution in Abia State, South-East Nigeria.
Statement
of the Problem
ECONOMIC BURDEN, PAYMENT STRATEGIES AND PAYMENT COPING MECHANISM AMONG TYPE2 DIABETIC PATIENTS ATTENDING A TERTIARY HEALTH INSTITUTION IN ABIA STATE, SOUTH EAST NIGERIA
