ECONOMIC BURDEN, PAYMENT STRATEGIES AND PAYMENT COPING MECHANISM AMONG TYPE2 DIABETIC PATIENTS ATTENDING A TERTIARY HEALTH INSTITUTION IN ABIA STATE, SOUTH EAST NIGERIA

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.
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 21^st 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
DM Type2 is preventable and controllable but increasing healthcare cost is a major challenge in accessing quality health care in Nigeria(Soyibo, 2009). Every year more than 150 million individuals face financial catastrophe and more than 100 million individuals are pushed into poverty as a direct result of paying for health care (Xu et al. 2007).  This could be worse for diabetic patients in Nigeria who not only require life- long treatment, make frequent visits to the health facilities but the three conditions that predicts financial catastrophe are prevalent in Nigeria; (Healthcare paid out of pocket (90%) (Soyibo 2009), poverty (70%) (UN Report, 2006) and lack ofprepayment mechanisms to pool risks)(Njoku, Ohagwu & Okaro 2010);   making affordability of the high cost of care often associated with chronic illness difficult.
These could hinder access to quality care leading to increased morbidity, mortality and productivity losses which spells ill for national development as the active productive age group are mostly affected in West African Sub- region (Obayendo, 2008).  The investigator as a nurse clinician observed that some patients came for follow-up appointment without investigation results, keep irregular appointments and report backwith severe complications.  Some dischargedpatients await bill settlement for weeks because of inability to pay.
One is bordered that despite the UN in 2011 raising the status of NCDs to that of HIV/AIDS, TB and Malaria because of their economic andhealth importance, there is neither support, norfinancial risk protection (exemption) for DM which is presently assuming an epidemic proportion (7%) of Nigerians and presence of development partners and Non- governmental organisation (NGOs) have not been felt in DM care (Sridhar, 2011).There is dearth of data on the magnitude of economic burden borne by Diabetics and their payment coping mechanisms in Nigeria.The researcher was persuaded to assessthese among Type2 diabetics, with a view of providing evidenced-based dataforintervention on the economic burden of diabetes mellitus through appropriate policy decision making.
 
The Purpose of the Study
This study determined the economic burden incurred and assessed payment strategies and payment coping mechanisms used by diabetics attending the Federal Medical Centre Umuahia.
 
Objectives of the Study
The objectives of this study were to:

• Determine the direct cost of care borne by patients in treatment of diabetes mellitus.
• Assess the indirect cost incurred by diabetics in accessing care for the disease.
• Assess the catastrophic cost to different socio-economic status groups of diabetics.
• Identify the various payment strategies used by diabetics.
• Identify payment coping mechanisms used by diabetic patients and their families in treating the disease.

 
Research Hypotheses

• There is no significant difference between socio-economic groups and catastrophic D.M costs.
• There is no significant difference between socio- economic groups and payment strategies used by the diabetics.
• There is no significant difference between socio- economic groups and payment coping mechanisms used by the diabetics.

 
Significance of the Study
The findings will expose the magnitude of the economic burden of diabetes from the perspective of the people living with diabetes (PLWD) and provide evidence to support advocacy positions to provide risk protection for diabetics and the other NCDs.
The findings from the study will be used to attract support from governmental and non-governmental organisations and agencies to support diabetic care.
It will also aid understanding of the economic impact of diabetes and challenge both administrators and clinicians to plan and implement qualitative and cost effective care that will reduce length of hospitalization and frequency of patients’ visits thus curb cost of diabetes care.
The findings can aid decision making on resource allocation to diabetes and other non- communicable diseases, prioritizing research funding and justifying funds for existing health problems and new (emerging) epidemics like diabetes.
It can also form an empowering instrument for the diabetics to pool their resources together, form strong support groups and ask for government support in terms of subsidy for treatment, exemption or securing insurance policy for diabetics as a social responsibility. Knowledge of cost incurred by individuals with diabetes will help clinicians and educators to provide useful advice to diabetics about controlling and reducing burden of diabetes on individual levels through effective self management. Understanding the magnitude of economic burden of D.M will provide basis for intervention on economic burden in terms of cost of illness and catastrophic costs. Understanding payment strategies and payment coping mechanism will provide evidence-base for improved financing, attention and co-ordination.
 
Scope of the Study
The study covered all diagnosed diabetics who have been receiving treatment from Federal Medical Centre Umuahia within the past one year (2011/2012).  Both males and females within the age bracket of 31-65 years were studied (hosts West African peak prevalence (31-50) and age of onset of increasing incidence of DM complications 65years).   The study involved outpatients attending FMC Umuahia.
 
Operational Definition of Terms
For the purpose of this study the following terms were defined as follows;

• Economic burden refers to direct, indirect and catastrophic healthcare costs incurred in managing diabetes mellitus.
• In this study direct cost refers to cost related to diagnoses, drugs, investigations, follow up costs, travel cost, etc. Indirect cost refers to monetary value of time spent travelling, waiting time in hospitals, time spent without working, time accompanying relative, time lost through premature death or premature retirement measured against the daily wage rate for individuals. Catastrophic healthcare expenditure of diabetes refers to spending on diabetic care of 40% or above of one’s non-subsistence (non-food) consumption expenditure. That is income available after basic needs have been met (WHO, 2005). For this study catastrophic expenditure thresholds 40%, 30% and 10% were used for all classes then 10% and 30% were considered for the poorest and the least poor respectively.
• Payment strategies are methods of payment for healthcare that  could be used by the diabetics:   out-of –pocket (oops) cash and carry, refund after payment, health insurance, exemption from payment, community based insurance (“isusu”) , NGOS , deferred payment, installmental  payment, in-kind  payment, pre-payment (off front payment) etc
• Payment coping mechanisms are the various means diabetics utilize in meeting up with the cost of medical care example own money (earmarked savings/earnings), money borrowed/loan, someone else paying, community based support, sale of household assets, gifts, appeal for support /begging, sale of land, temporary stoppage of children’s education, Government support (social welfare waiver), cutting down on minimum consumption expenses ,diabetes association social support,  including cost saving/cost evading behaviours like skipping appointment when feeling strong (deferred visit), skipping of doses of drugs to last longer,  use of alternative treatment methods etc.
• Type2 Diabetic patients are individuals with physician’s diagnosed diabetes mellitus except gestational D.M.

Socio-economic status  refer to the categorization of respondents into different classes based on the acquisition of household assets like radio, television, bicycle, motorcycle, air conditioner, electric fan, fridge, generator, gas cooker and car and their food and other household expenditure on an assets based socio-economic status (SES) index. It was used as proxy for income