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VINCENT KURAUN looks at the painful situation of cancer patients bearing the expensive cost of treatment and why government must do more to save its citizens from cancer deaths.
Mrs Bright (Not real name) was terrified when she was diagnosed with breast cancer. She worried about her chances of survival and the side effects of the proposed treatment, but what she didn’t anticipate was the financial toll the disease would take on her family. As a federal civil servant, she had thought that her health insurance package will cover the cost of her cancer treatment.
But the reality of her situation soon dawned on her after the oncologist enlisted for her treatment recommended a six-course chemotherapy which her insurance company refused to cover. Even the cost of drugs was killing. Her family members and friends had to raise funds which were soon expended within few months forcing her to skip her appointment with the hospital.
Like Mrs Bright, similar stories are becoming more common as the cost of treating cancer and caring for people living with it grows more expensive. Most affected patients foot the bill for their treatment because the health insurance policy in the country does not cover cancer treatment comprehensively. This partial exclusion had caused a lot of deaths and increased the number of patients suffering from chronic cancer disease, as many cancer patients would begin treatment but stop midway because they could no longer bear the financial burden of treatment.
From the records of National Cancer Control Plan 2018-2022, cancer is claimed to be responsible for 72,000 deaths in Nigeria every year with estimated 102,000 new cases annually. This number is expected to increase as findings have shown that the cost of treating cancer remains prohibitive and the management of cancer involves the use of a multi-modal approach which includes surgery, chemotherapy, radiotherapy, nuclear medicine, palliative care, among others.
But to what extent do cancer patients get care in the country. Does the government even make enough attempt to save its citizens from cancer deaths? Though there is a National Health Insurance Scheme (NHIS), in what way is the agency assisting sufferers that have enrolled in the national heath scheme?
Professor Mohammed Sambo, Executive Secretary of NHIS, at a News Agency of Nigeria forum held in February last year in Abuja had explained the limitation the agency faced, stressing that with sufficient funds in the health insurance pool, the scheme would expand its package to include medical conditions not currently covered like cancer. He then disclosed that the establishment of a Catastrophic Fund was being planned to specifically address terminal diseases. He also expressed the optimism that NHIS’ collaboration with drugs manufactures, in a plan that would affect direct supplies to hospitals, would ensure affordability and availability.
Also, in another briefing by Sambo, he explained why NHIS cannot fund cancer full-scale. “It would be difficult for us to take the burden of treating cancer completely, because the cost is enormous. If you have many cancer patients who are supposed to get comprehensive treatment and under the social health insurance, it will be very difficult.”
However, despite the insufficient funds available, the scheme covered some aspect of cancer treatment, for example, surgeries that are cancer related are covered in the national health insurance scheme. Mastectomy is one of such, a woman who has cancer of the breast will require a surgery probably the partial removal or total removal of the breast. This procedure is covered under the scheme.
For chemotherapy, some of the drugs are covered but not as comprehensive as a total package for a cancer patient. It was observed during our findings that for Cytotoxic and Adjuvants drugs which are under partial coverage for which NHIS has been able to enter MOU with pharmaceutical companies, NHIS covered the drugs on a shared ratio of 50:30:20 (pharmaceutical company: NHIS: enrolee). For Cytotoxic drugs, where NHIS is unable to enter into cost sharing arrangement with pharmaceutical companies, NHIS will be able to offset only 30 per cent of the cost of the drugs. In spite of the aforementioned ratios, NHIS contribution will not exceed N1 million per patient.
Also there is limited radiotherapy that is covered in the health insurance scheme. Radiotherapy treatments are under partial coverage (50:50) according NHIS operational guidelines. Also, NHIS contributes a prorated maximum of N400,000 only for radiotherapy treatment per patient. It was observed also that some cancer patients are required to run test like MRI and CT scan and according to NHIS operational guidelines, high technology investigations like CT scan, MRI are under partial exclusion. What that means is that, the HMO would pay 50 per cent of cost while the remaining 50 per cent would go to the patient.
Heavy Burden of Cancer Treatment
But is this coverage of cancer treatment enough to lessen the burden on patients? While speaking with Sunday Tribune, Dr Leke Oshunniyi, chairman of the Health and Management Care Association of Nigeria, which is the umbrella body of health maintenance organisations (HMOs) and Managing Director Aiico Multished Limited, provided insight into government’s intervention in the treatment of terminal diseases, particularly cancer. According to him, there is a standing arrangement for the provision of cancer drugs.
“The National Health Insurance Authority (NHIA) has a relationship with a pharmaceutical company and the company has agreed to discount the price of anti-cancer drugs by 50 per cent while the enrolee pays a certain percentage and the NHIA pay another percentage under the NHIS plan.”
The NHIA, he explained further, is also making arrangements with all “drugs manufacturers to brand drugs as NHIA so that it will bring down the cost considerably under the scheme,” adding that the plan would also cover other drugs and not just the ones for cancer.
“It is not just anti-cancer drugs, there is whole project to brand drugs as NHIA medication. It is a massive project involving agencies like Nigeria Customs, National Agency for Food Drug Administration and Control (NAFDAC ) to lower the cost of care not just for cancer but even for other diseases. Initiatives are ongoing to lower the cost of delivering health care to Nigerians which is the aim of the scheme.”
Dr Adeniji Adeoluwa, a consultant clinical and radiation oncologist and Medical Director Me Cure Cancer Centre, also acknowledged the difficulty cancer sufferers undergo in the country to get treatment, especially where there is limited of funds.
The situation until recently, according to him, was very bad. But government, he disclosed had since put some measures in place. “When it comes to treatment of cancer patients or people living with cancer and funding, government in recent times has tried to do a number of things. Before, it was really bad, such that every single thing a patient would need would be paid for by himself. So we call it out of pocket payment.
“Also the private insurance won’t even cover anything that has to do with cancer care. But government has come up with some new strategies and collaborations which are making things better in a way. For example, I am fully aware of the fund that is available for people with cancer to be able to access care. Government is helping with that and there are hospitals in different geopolitical zones where arrangement has been made in such a way that indigent cancer patients can [get treatment]. It is not in all government hospitals, but some hospitals have that arrangement.
“There is also an arrangement where patients can have access to drugs at a very minimal cost, very cheap. There are drugs that come at a very high cost, so government is trying to create this access pathway such that even though patients will have access to it, they will not have to pay too much. It is a collaboration with some organisations, for example, there is one we call CHAI (Clinton Health Access Initiative). The federal ministry of health also is doing a lot in that regard, but I must say that there are still many people, several people that are yet to have this coverage. So, government still has more work to do. They need to come out with more strategies that will cover more people, more hospitals and increase the funds to help people with cancer so that more people can benefit from it.
“When we talk about cancer care, it doesn’t just stop with patients going to the hospital, having access to drugs, we are also talking about the availability of the specialists, the team that will treat them; we are also talking about infrastructure.
“Radiotherapy machines are very few in Nigeria. There are some states that don’t have single radiotherapy machine. So the people in those states will need to move to other states. And there are also states in this country that do not have any specialist in oncology. They just have probably other doctors who are treating cancer, but who are not specialists in that field. So they may not be able to give the best care,” Adeoluwa explained, adding, however, some of the infrastructural and personnel challenges are already being bridged by the private sector health care operators who have acquired PET/CT scan, Positron emission tomography and computed tomography, among others.
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On what the Association of Clinical and Radiation Oncologists of Nigeria ARCON is doing to ameliorate the high cost of cancer treatment in Nigeria, Dr Adeniji said “the association is doing a lot. The association is not a financial body, and so, they may not be able to put funds on ground directly. However, there is a role that advocacy plays. For example, what you are seeing from the government side is one of the results of what ARCON is doing. We have been able to talk to the government about the need for health insurance and the need for more infrastructure and for more specialists to be trained. That is what we are seeing now and also, we are having some form of collaborations. For example, the availability of drugs through the drugs access pathway came because of the way ARCON actually took it up that our patients cannot keep dying because they cannot afford drugs.
“The drugs access pathway first came in as a form of training for doctors and then, the institution came up with strategy to distribute drugs at a very cheap price. So we are doing a whole lot to let the government know, and let the private institutions know and also people in the other parts of the world who may want to collaborate to help our patients here.”
Why Early detection of cancer matters
On what to do prevent cancer deaths, Dr Adeniji said, “when it comes to treatment of cancer, early detection saves lives. We need to detect it very early and the best way to detect it early is to do a routine check-up or annual check-ups or screening programmes as we call it. People need to go to the hospital and find a way to be able to be screened for breast cancer, cervical cancer, lungs cancer, colon cancer and many other types of cancer.”
People, he said, can also do self-examination. “For example, a woman can examine her breasts at home and know if there is anything abnormal before even going to the hospital. That alone is a major thing to do, and there are other things that we can do to prevent cancer like vaccination against HPV, Human Papilloma Virus. You know we have Gardasil, we have Cervarix, we have them by their names, so, the vaccines are not readily available in Nigeria, but we have centres that have the vaccines. But the vaccines don’t come cheap, people will have to pay to be able to access them, unlike the regular vaccines we have in Nigeria when you can give children free of charge.”
Why Cancer needs Special Attention
Explaining the danger in allowing the country’s cancer situation to remain as it is, Adeniji said the disease needs more specific attention from government and strategies to halt the surge. Number one of such strategies, according to him, “is to ensure that we have enough team on ground to treat patients. I am talking about specialist oncologists, radiographers, nurses, and the entire oncology team and then, ensure that they are available. Many of us are leaving the country very fast; after being trained, they are leaving. Some don’t even wait till the end of their training; they just go to the UK, go to US. So, government needs to look into that. Otherwise, there could be a time that there won’t be enough oncologists. We don’t even have enough from the beginning, but we don’t want to get to a point that there won’t be any oncologist that would treat Nigerians that have cancer.
“Number two is infrastructure. Infrastructure should be developed; we need comprehensive cancer centres where a lot of things can happen including PET/CT scan, diagnosis arms, including tumour board facilities and to make equipment: radiotherapy machines both brachytherapy, external beam and other therapy machines, readily available. Nigeria should get enough and put at least one machine in every state.
“Also Nigerian government should ensure that the fund they are making available for cancer patients goes round; it shouldn’t just stay with few people. There are many Nigerians with cancer, so the funds should go round, they should make more funds available as much as possible and then drugs access pathway should be readily available so that people will not have pay too much to get the necessary drugs and, of course, advocacy is very important. They should support NGOs, the oncology group, all the hospitals that are trying to push out advocacy to ensure that people are aware of what is going on and people can come in for screening and if government can screen free of charge, it will be fantastic.
“There are things that private institutions or hospitals are doing to import a lot of medical equipment, government should find a way to reduce the tax or make them tax-free; increasing tax will discourage the investors from bringing in the necessary equipment to help Nigerians. Government should encourage investors, encourage the importation of equipment and make it very easy for people to be able to invest and then, set things up,” he said.
A lot therefore still needs to be done by the government to reduce the cost of treating cancer in Nigeria and at the end lessen the burden on cancer patients. One idea for lowering the cost is to tie them to the level of clinical benefit provided by the health insurance scheme.
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