IBADAN, Nigeria — Last summer, health care practitioners across Nigeria rallied through social media to raise funds for a colleague, Nengi Rachel, who had been diagnosed with angiosarcoma, a rare type of cancer. A GoFundMe page was set up and over $26,000 raised.
It’s a familiar trend. Across Nigeria, cancer patients and their relatives are turning to social media to raise funds for their treatment — a consequence of the country’s broken health insurance system, which does not cover cancer, said public health expert Dr. Lawal Bakare.
“[Cancer treatment] is out of the reach of anybody. I pray that I don’t have cancer because, even as a doctor, I will not be able to fund it.”— Dr. Francis Adedayo Faduyile, president, Nigerian Medical Association
“Whenever you read these stories of people seeking medical support ... just remember that we have all [been] failed [by] our National Health Insurance Scheme ... No amount of personal donation to cancer care ... will fix the massive gap,” he said.
A major government plan is now focused on increasing cancer treatment facilities nationwide — but experts said investments in equipment must come alongside investments in affordable access to have any impact.
In 2018 alone, there were about 116,000 new cases of cancer in Nigeria and over 70,000 deaths — higher than the estimates for HIV/AIDS. While data is limited, estimates from the Institute for Health Metrics and Evaluation suggest that the cancer death rate in Nigeria was 113.7 per 100,000 people in 2017, versus 99.2 per 100,000 people in Kenya.
Moreover, experts including Dr. Razaq Oyesegun, a consultant oncologist at Nigeria’s National Hospital in Abuja, believe that the cancer figures are under-reported. Since many patients cannot afford the costs, they often abandon hospital tests and treatment, he said, meaning they won’t be captured in the data.
Read more about health care in Nigeria
One study estimated that at least 72% of breast cancer patients in Nigeria pay out-of-pocket for their treatment, in comparison with at least 45% in Ghana, and just 8% in Kenya, where most of the costs are covered by the country’s health insurance scheme.
Women are disproportionately affected — breast and cervical cancers are responsible for more deaths than any others in Nigeria, though elsewhere they have among the highest survival rates. A mastectomy typically costs around 250,000 Nigerian nairas ($700) — far beyond the reach of most patients. An additional problem is that finances are often in the hands of a husband or male relative, who may not wish to pay for treatment, Oyesegun explained.
For those who do manage to afford diagnosis and treatment, the time spent fundraising may allow cancers to spread.
Rachel flew to India for treatment after raising the funds but, having waited two years for a diagnosis, she did not survive.
Limited insurance coverage
At the launch of Nigeria’s National Health Insurance Scheme in 2005, former health minister Eyitayo Lambo said it would ensure Nigeria achieves universal health coverage and would enable Nigerians to access health care services without having to pay out of pocket.
Although it was meant to be Africa’s largest health insurance scheme, only about 4% of Nigerians have signed up. These are mostly government workers who are automatically enrolled. By comparison, Ghana’s health insurance scheme, launched around the same time, has reached about 40% of its citizens.
The scheme has been plagued by leadership issues and technical challenges, but it is also unattractive to many Nigerians because it fails to provide cover for many advanced medical procedures. On the list of ailments excluded from the scheme are terminal illnesses, including cancers. Diagnostic tests such as mammography, Pap smears, and tumor markers are also not covered.
In response to queries about this, insurance scheme officials directed Devex to a special assistance program that supports some aspects of cancer diagnosis. But the scheme only covers 10% of the cost. The patient is required to cover the rest.
Ayo Osinlu, head of media and public relations for the insurance scheme, pointed to its limited purse. “As a way of protecting the fund, financially-intensive health conditions were either partially or completely excluded, in the hope that as the pool of funds increases, we can extend coverage into those illnesses. A young insurance scheme like NHIS that started in 2005 could not have been able to take care of all illnesses,” Osinlu said.
The Nigerian Medical Association described the exclusion of cancer as unacceptable.
“Cancer treatment is terribly expensive,” said NMA President Dr. Francis Adedayo Faduyile. “It is out of the reach of anybody. I pray that I don’t have cancer because, even as a doctor, I will not be able to fund it.”
Faduyile believes NHIS could handle the costs. For example, Ghana’s health insurance scheme, which launched around the same time, covers the cost of treating breast and cervical cancer, though not most other types.
NMA has lobbied the Nigerian government to subsidize the cost of cancer treatment, and to make NHIS mandatory for citizens to ensure that more funds are available.
Read more about cancer care
Last year, the Nigerian government launched the country’s $250 million National Cancer Control Plan for 2018-2022 with the goal of reducing the cancer prevalence and mortality rates.
To improve treatment, the plan aims to increase the “number of comprehensive cancer care centers in the country that can offer radiotherapy as part of treatment for cancer patients.”
But experts said this investment is pointless if patients cannot afford to use the centers.
Recently, new radiotherapy machines were acquired for the National Hospital in Abuja and a federal government-owned hospital in Lagos. Oyesegun, a consultant at the Abuja facility, told Devex that the new machine has not had any impact on reducing the cost of treatment. Instead, it has only helped reduce the number of Nigerians traveling abroad for treatment — who could already afford it.
Health Access: A series for achieving UHC
“Because the centers are required to be self-sufficient and not rely on the government for maintenance and servicing,” the cost of treatment in government-owned hospitals is similar to that of private facilities, he explained.
Health care giant Roche is a partner for the National Cancer Control Plan. Nigeria country manager Hameed Oladipupo told Devex that the government needs to work more closely with partners in order to provide better care.
“This ecosystem cannot be developed by one or two organizations. You need a multitude of people to come in with ideas, investments and processes that can support government to ensure that we implement the right things,” Oladipupo said.
He argued that Nigeria needs a signal of commitment from the government. “Investors will naturally come in to provide their services once they know that payment will be obtained. And they can sign contracts with investors to provide services for patients and receive payments after one or two years … That is what other countries have done. It doesn’t work perfectly but it ignites a process that brings about ... positive change,” he said.
Despite the strides in countries such as Kenya, Oladipupo believes no African country has yet got it right — but more lives are at least being saved.
In the meantime, alternative models are emerging in Nigeria, including charitable ventures — though highly limited in scope — and state-level initiatives. Jennifer Dent, president of BIO Ventures for Global Health, which is working on a cancer drug partnership program in some areas of the country, said finding a way to cover the cost of treatment was a “priority.”
“I’m very optimistic and hopeful that we will see some announcement from the president ... [to] provide some coverage under the NHIS for cancer treatment and care,” she said.
At NHIS, a new leader has also been appointed which some are hoping could herald change.
For Oladipupo, it can’t come soon enough. “At the end of the day, we are all potential patients … We all crave for this change and difference in the way the system works,” he said.
For a closer look at the innovative solutions designed to push for progress on universal health coverage around the globe, visit the Healthy Access series.