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 Table of Contents  
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 1-5

Out-of-pocket expenditure on HIV/AIDS services in Nigeria

1 Department of Programme Coordination, National Agency for the Control of AIDS, Abuja, Nigeria
2 Department of Strategic Knowledge and Management, National Agency for the Control of AIDS, Abuja, Nigeria
3 Department of Public Health, Olabisi Onabanjo University, Ago-Iwoye, Nigeria

Date of Web Publication1-Mar-2018

Correspondence Address:
Dr. Chinwendu Daniel Ndukwe
Department of Programme Coordination, National Agency for the Control of AIDS, Abuja
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_3_17

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CONTEXT: Financial catastrophe can arise from huge out-of-pocket (OOP) expenditure on HIV-related care and treatment. Despite the huge burden of HIV and high poverty headcount ratio in Nigeria, there is dearth of information on the OOP expenditure among People Living with HIV (PLHIV).
AIMS: This study aims to assess OOP expenditure on HIV/AIDS services among PLHIV in Nigeria.
SUBJECTS AND METHODS: The study was a cross-sectional survey of PLHIV accessing HIV/AIDS services in health facilities across five states in Nigeria. A multi-stage sampling approach was adopted, and two pretested questionnaires were used for the assessment. Descriptive analysis was conducted using SPSS version 16.
RESULTS: A total of 485 PLHIV accessing care in 26 health facilities were surveyed. About 59.9% of the respondents were employed while 50.4% PLHIV were the main breadwinner for their household. The average annual personal income was N357, 516 ($2,235) and the annual household income was N586, 584 ($3,666). The proportions of household expenditure on healthcare food and transport were 23.0%, 33.5% and 13.1%, respectively. The average annual expenditure for HIV care was N84, 480 ($528). The proportion of the household income used for HIV care was 14.5%.
CONCLUSIONS: OOP expenditure for HIV related services among PLHIV in Nigeria seems to be catastrophic. There is a need for policy response toward financial protection for PLHIV and abolishment of user-fee where it exits.

Keywords: Expenditure, HIV/AIDS, Nigeria, out-of-pocket

How to cite this article:
Ndukwe CD, Ibekwe PN, Olakunde BO, Ogungbemi K, Fatungase KO, Anenih JO, Anosike AO, Adeoye I. Out-of-pocket expenditure on HIV/AIDS services in Nigeria. Int J Health Allied Sci 2018;7:1-5

How to cite this URL:
Ndukwe CD, Ibekwe PN, Olakunde BO, Ogungbemi K, Fatungase KO, Anenih JO, Anosike AO, Adeoye I. Out-of-pocket expenditure on HIV/AIDS services in Nigeria. Int J Health Allied Sci [serial online] 2018 [cited 2018 Mar 17];7:1-5. Available from: http://www.ijhas.in/text.asp?2018/7/1/1/226258

  Introduction Top

With a population of about 170 million and HIV seroprevalence of 3.4%, Nigeria ranks as the second highest HIV burdened country in the world after South Africa.[1] Current estimates indicate that about 3.4 million people are living with HIV/AIDS.[1] In 2014, new HIV infection was estimated at 227,518, while AIDS-related annual mortality was 174, 253.[1] An important consequence of this huge burden is the devastating effect on the microeconomy and macroeconomy.[2],[3],[4]

HIV/AIDS is known to have severe economic effect in high burden countries. At the micro level, the economic effect arises from direct costs such as expenditure on HIV-related care and treatment and indirect costs such as lost time due to the illness.[2] The economic impact of HIV/AIDS is experienced first by individuals and their households before it extends to the macroeconomy.[5] Thus, HIV/AIDS-related out-of-pocket (OOP) expenditure is argued to be the most important component that should be examined for the economic impact of HIV/AIDS.[6]

OOP expenditures are the direct and indirect expenses incurred by an individual or household to secure or maintain their health. It is a key source of health financing in many developing countries. In Nigeria, it accounts for >90% of the private health expenditure.[7] High OOP payments for healthcare services can drive individuals or households into poverty.[8],[9] Owing to financial catastrophe from high OOP expenditure, households might not be able to meet basic needs such as food, clothing, and shelter.[10] OOP expenditure has also been shown to affect health-seeking behavior and access to care.[11]

People living with HIV/AIDS (PLHIV) incur substantial OOP expenditure for HIV-related health care.[12],[13] OOP expenditure for PLHIV includes medical cost associated with HIV-related care and treatment such as formal fees charged for antiretroviral (ARV) drugs, laboratory tests, consumables, and hospitalization. Access to free or subsidized HIV/AIDS services can potentially reduce OOP expenditure by PLHIV.[14] However, studies have reported that where only ARVs are free or subsidized, expenditure on HIV care can still be catastrophic.[15],[16] Medical costs also include informal or unauthorized fees charged by healthcare providers. Such expenditure is not uncommon and may constitute a significant portion of OOP expenditure. Another form of OOP expenditure is nonmedical expenses associated with HIV-related care and treatment.[17] Nonmedical expenses such as the cost of transportation to a health facility, accommodation, and food could serve as major deterrence to accessing HIV/AIDS services.[18],[19]

The poverty headcount ratio at the national poverty line in Nigeria is estimated at 46%, despite a gross domestic product (GDP) of $262.6 billion and a GDP growth rate of 6.2%.[20] Clearly, a number of individuals and households in Nigeria are susceptible to catastrophic health expenditure. Thus, giving the huge burden of HIV/AIDS in Nigeria, an understanding of the microeconomic impact of HIV/AIDS at the individual and household level is imperative if the economic impact of HIV/AIDS is to be mitigated.[5] With dearth of information on HIV/AIDS spending attributable to OOP expenditure in Nigeria, this study assessed OOP expenditure among PLHIV in Nigeria.

  Subjects and Methods Top

The study was a cross-sectional survey of PLHIV accessing HIV/AIDS services in health facilities in Nigeria. The study was conducted in 26 health facilities offering comprehensive HIV services across five states (Lagos, Akwa Ibom, Cross River, Benue and Abia) in Nigeria. It was done between October and December 2011.

The study adopted a multistage sampling approach. Five states were selected as listed above. In each selected state, antiretroviral therapy (ART) sites were stratified into private and public facilities and four to five sites were randomly selected from public health facilities while one site was selected from privately-owned or faith-based facility.

In each of the selected health facility, 19 consecutive clients (PLHIV) who were 18 years and above during the survey period were recruited to the study. For every client that refused to participate in the study, the next consecutive client was selected. A total of 485 PLHIV accessing care in 26 health facilities were included in the survey.

Two pretested interviewer-administered questionnaires were used for the assessment. The questionnaire included questions on major components of HIV care and support, with a view to identifying OOP expenditures and areas where they were incurred by PLHIV. The service user questionnaire sought information on the composition of the household, economic status, and spending on HIV/AIDS services in the past 1 month from the PLHIV. Data on income and expenditures were collected in Naira but converted to the US dollar using the prevailing exchange rate of N160 at the time of the study.

The data collected by trained data collectors were randomly selected and assessed for error. Data cleaning was also undertaken before data analysis. We calculated simple proportions using SPSS Version 16.0. (SPSS Inc., Chicago).

Institutional approval to conduct the study was obtained from the relevant ministries of health and head of the facilities where the study was conducted. Informed consent was obtained from all the respondents who were assured of the utmost confidentiality of the information obtained from them.

  Results Top

Response pattern and characteristics of respondents

A response rate of 99.8% was achieved. About 61% of the respondents were aged 20–39 years, 36% had never been married while 45% were married. About 27% had tertiary education, 71% had at least secondary education while the rest had primary or no education [Table 1].
Table 1: Respondents' profile

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Household and economic profile

About 50% of the household had a size of >4 [Table 2]. About 17% of households had >2 household members working and 44% of households had only one person working. About 50.4% of the PLHIV were the main breadwinners for their households. At the time of the survey, 59.9% of respondents were gainfully employed and about 60% them were self-employed (Data not shown). The reasons why some PLHIV were not employed were as follows: could not find a job (43%), ill health (23%), studying/in training (20%), retired (9%), and others (5%) (data not shown).
Table 2: Characteristics of households

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Personal and household income and expenditure pattern

The average monthly personal income was N29, 793 ($186) while the average monthly household income was N48,882 ($306). On the distribution pattern of monthly personal income, 24.2% earned ≤ N 5,000 ($32) which is about a dollar per day while 12.7% of the household had income ≤ N 5,000 ($32) [Table 3]. On the pattern of expenditure, the proportion of monthly household expenditure on healthcare was 23.0%, while food and transport were 33.5% and 13.1% respectively [Table 4].
Table 3: Distribution pattern of respondents' reported personal and household income

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Table 4: Summary of average monthly household expenditure

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Service user fees and charges

Respondents were asked about the payments they made for different aspects of HIV care and services in the last 1 month. The annual expenditure ranged between N100 (<$1)– N87, 000 ($544) with an average of N84, 480 ($528). Thus, with about 359,181 people currently on ART (as at 2010), the estimated total OOP expenditure on HIV care was N30,343,610,880 ($189,647,568). Based on an average annual household income of N586,584 ($3,666) and average annual OOP expenditure of N84,4480 ($528), the proportion of the household income that was used for HIV care was 14.5%.

Patients' expenditure included: consultation fees, hospital registration fees, non-ARVs, ARVs, laboratory tests, radiological tests, transportation, food on clinic days, accommodation, traditional medicines, and nutritional supplements [Table 5]. Majority of the respondents did not pay for laboratory services (80%) and ARVs (91%).
Table 5: Range of payments for HIV services in the past 1 month

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  Discussion Top

PLHIV require a range of preventive, short- and long-term healthcare services and evidence has shown that economic status is a key determinant of access to and utilization of these healthcare services.[11] With substantial income, a household or individual is likely to meet the direct medical and nonmedical costs associated with HIV care services. Inability to meet these costs could result in poor health-seeking behavior and retention in care. In this study, high proportion of the respondent had low economic status. About a quarter earned less than a dollar per day while 72% had an average monthly income that was <N30,001($115). Our findings do not compare with a study in 14 ART sites which reported 56% had monthly income <N30,000($150).[21]

Morbidity due to HIV has an impact on productivity and can result in loss of job. Out of those unemployed in this study, 23% reported it was due to ill health. Reduced productivity or lack of job becomes highly significant if the person involved is the breadwinner of the household. About 50.4% of the PLHIV in this study were the main breadwinners for their households. Thirty-three percent of the respondent had the desire to work, but could not find a job. However this could be due to the high rate of unemployment in the country. Another possibility, perhaps accounting for few cases, might be the HIV status. Some companies restrict their recruitment practices to reduce HIV/AIDS-related costs such as costs associated with premature retirement, death, and disability benefits.[22] However, the HIV/AIDS anti-discrimination law of Nigeria, with well-defined provisions, adequately addresses the issue of unemployment and job security among PLHIV.[23]

HIV/AIDS services in Nigeria are largely donor supported. These services, where available, are meant to be provided free of charge. However, an assessment of HIV service provision by Amanyeiwe et al. reported that some health facilities charged certain fees for ART, PMTCT, and laboratory services.[24] In this study, PLHIV were found to pay considerably for medical costs such as consultation, hospital registration, ARVs, Non-ARVs drugs, and laboratory services as well as nonmedical costs such as transport to the health facility and cost of food on clinic days. A significant proportion of the household income (14.5%) is used for HIV/AIDS care in our study. Using a threshold of 10% of income,[25] this level of expenditure is catastrophic.

Some of the respondents access services in the private sector, many of which provide services at certain fees. This may explain the huge expenditure for HIV care. Unfortunately, in some public health facilities where these services are available for free, stock-out of drugs and commodities, and breakdown of laboratory equipment are common challenges. PLHIV Consequently, who would rather get services from public facilities are forced to the private facilities, necessitating them to pay for some of the services they would have accessed free.

Risk pooling of healthcare expenditure can provide financial protection and mitigate against the impact of OOP expenditure on PLHIV. In areas with access to health insurance, OOP expenditure on HIV has been observed to be low.[16] Clearly, there is a need to expand the current scope of the health insurance scheme in Nigeria to cover HIV services.

The evidence from this study is in line with Mahal et al. who found that direct and indirect costs of morbidity associated with HIV/AIDS resulted in huge OOP expenditure on healthcare by HIV-positive individuals when compared with matched HIV-negative individuals in Nigeria.[26] However, our finding is not consistent with a study in Nigeria which reported 45.6% for Oyo state and 27.5% for Plateau State on OOP expenditure by households as a percentage of annual per capita expenditure.[27] These estimates were for hospitalized PLHIV, possibly accounting for the huge variance. Furthermore, the annual estimated OOP expenditure in this study is higher than the $432 that was reported by Health Reform Foundation of Nigeria. The study was, however, lower in scope, involving 144 PLHIV across 14 ART sites.[21] Similar studies in other setting have also reported a huge OOP expenditure despite free or subsidized ARVs.[15],[16]

Our study is not without limitations. The data reported in this study were collected in 2011. Given the recent economic downturn, it should be interpreted with a caution. The expenditure reported by the respondent may have been over or under estimated as the self-reporting methodology used is subject to recall bias. The study only assessed direct cost, further studies are needed to understand the indirect costs incurred by the PLHIV. Finally, the study was conducted only in six states out of the 36 States and the Federal Capital Territory in Nigeria. A comprehensive health survey of OOP expenditure on HIV/AIDS services among PLHIV with a representative sample is required for more generalizability.

  Conclusions Top

OOP expenditure for HIV related services among PLHIV in Nigeria seems to be substantial and catastrophic. Financial mechanism such as health insurance scheme that will ensure financial protection for PLHIV should be setup. User-fee for HIV/AIDS, where existing, should be abolished or heavily subsidized.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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