Cost of Managing
Chronic Hepatitis B in a Resource-Poor Setting; The
Implications for Universal Health Coverage Reform
AloniAdolphus ALALI1*, Alali
DAN-JUMBO2, Daprim Samuel OGAJI (Prof.)3
1Department of Community
Medicine, Rivers State University, Nkpolu, Port
Harcourt, Nigeria
2Department of
Family Medicine, Rivers State University, Npkolu,
Port Harcourt, Nigeria
3Africa Centre
of Excellence in Public Health and Toxicology Research (ACE PUTOR), University
of Port Harcourt, Choba, Nigeria. ORCID ID: http://orcid.org/0000-0002-4257-1579
Introduction: Hepatitis B (HBV) is a global public health problem whose management
imposes financial hardship on the patients especially in developing countries
with high level of poverty. This study estimated the financial burden of
managing HBV by quantifying the direct medical, direct non-medical and
indirect costs of managing patients in various stages of chronic hepatitis B
virus disease.
Methods: This was a descriptive cross-sectional survey
that retrospectively collected data on direct medical costs, direct non-medical and indirect costs through interviewed
patients. Cluster sampling method was employed to recruit 107 hepatitis B
patients at various stages of the disease.
Data was analysed using Statistical Package for the Social Sciences
(SPSS) and frequencies presented in tables and charts.
Result: The extrapolated annual direct medical cost of managing hepatitis B
for a patient is ₦354,613 ($933). Additionally, patients who patronised
herbs and other forms of alternative medicine spend an average of ₦205,000
($540) per year as part of their direct medical cost. The direct non-medical
cost of managing hepatitis B is ₦50,446 ($133) per patient per year.
The indirect cost is ₦159,900 ($421) per patient per year. The total
cost of managing a chronic hepatitis B patient per year is ₦564,959
($1,487)
Conclusion: The average amount needed to treat this condition
is more than the minimum wage of the average patient. There is therefore the need to reduce exclusion
and social disparities in patient with chronic HBV through introduction of
subsidies for the treatment of chronic hepatitis B as well as establish
pre-payment mechanisms that can reduce the need to pay out-of-pocket for
their treatment.
Keywords: Hepatitis B, Cost of care, Universal
health coverage.
BACKGROUND
Hepatitis B is a potentially life-threatening blood borne disease that
affects the liver. It is the commonest infective cause of liver disease that
could result in liver cirrhosis and cancer. In WHO African region, over 81
million people are infected with hepatitis B second only to WHO pacific region
where it affects 116 million people (1). Hepatitis B virus (HBV) occurs
worldwide with high endemicity in sub-Saharan Africa
where it is hyper-endemic (prevalence rate >8% of the population), also in
Southeast Asia and the Pacific. The prevalence rates in North America, Western
and Northern Europe are as low as 0.1% of the population.(2).
Nigeria, with the prevalence of hepatitis B virus infection at 11% accounts for
8.3% of the global burden of chronic HBV. The distribution of hepatitis B virus
infection by sex in Nigeria is 62.6% male and 37.4% female (3)
Hepatitis B is a global public health problem whose management
imposes financial hardship on the patients especially in developing countries
with poor health coverage (4). Studies in other parts of the world have shown
the cost of treating hepatitis B to be quite high as compared to other
illnesses (5 - 7),For a country like Nigeria where up to 95.8% of her citizens pay
out-of-pocket for health care, it is important to estimate the cost of managing
hepatitis B in order to plan appropriate interventions for such
patients(8).
Cost of illness as a part of cost analysis, is one of the basic
tools of economic evaluation used to measure the economic burden of a disease
or group of diseases and by extension estimate the amount that can be
potentially saved or gained by preventing the disease. It is a broad concept of
cost that involves both cost from the patients’ perspective and cost from the
providers’ perspective(9). Cost from the patients’
perspective involves direct medical cost, direct non-medical cost and indirect
cost. It refers to all costs that are completely attributable to the use of a
healthcare intervention or illness.(9, 10)
Essentially, direct medical cost include the cost of services such
as consultation, drugs, investigations and admission/hospital stay (9). It
refers to to all costs due to resources use that are
completely attributable to the use of a healthcare intervention or illness.(12) Direct medical costs specifically refers to the cost
of a defined intervention or all follow-up costs for medications and other
healthcare interventions in ambulatory, inpatient and nursing care.(12) It
traditionally involves the medical care expenditures for the diagnosis,
treatment and rehabilitation of a patient.
While direct non-medical cost captures costs related to
transportation, meals, and patient accompaniers (9). It refers to expenditures
as the result of an illness but are not involved in
the direct purchasing of medical services. It often includes such expenditures
as travel, lodging, home services and is related to the consumption of other
non-healthcare resources like transportation, household expenditures,
relocating, property losses, and informal care of any kinds.(13).
Henry Flood and Richard Phelps started their article on
understanding indirect cost with a quote “they may be hard to figure and even
harder to recover, but they should never be overlooked”(15).
Indirect cost refers to the loss of resources due to morbidity and mortality,
which inadvertently places a monetary value on the value of human life. For
many studies, indirect costs are substantial and can be significantly higher
than the direct cost.(9) There has been widespread disagreement about the
methods of estimating indirect costs and a lot of it arises from ethical
considerations as the idea of placing a monetary value on life raises ethical
questions. Because lower values are placed on the elderly and those who do not
work, the controversy continues whether such costs should be included in the
cost of illness.(9) There are three approaches
currently used in estimating indirect cost. They include the human capital
method, the friction cost method and the willingness to pay method.
The contributions of direct non-medical costs and indirect costs
are often not comprehensively assessed because these data are difficult to
collect retrospectively and the methods for collecting them are not very well
established. (14) These costs are however very important from a societal
perspective and studies have suggested that they represent a significant
proportion of the total cost in certain settings. Cost estimates that exclude
these other cost components will grossly underestimate the cost of treatment of
a condition, especially treatment that depends a lot on the patient’s time and
that of their care-givers.(14)
A nationwide study conducted in Greece estimated the average cost
of illness per year of hepatitis B to be at 2,979 Euros(6).
A similar study in Germany placed the average cost at DM 5,974(16). Another
study on the direct economic burden of hepatitis B virus-related diseases in
Shandong, China, considered the direct medical cost to include total
outpatient, inpatient (hospitalization expenditures, nursing, prescription
drugs and examination fees) and self-treatment expenditures. This study did not
include costs of diagnosis (laboratory test and procedures) as direct medical
costs but it estimated the costs of various stages of hepatitis B virus disease
focusing on hepatitis B virus-related diseases like acute hepatitis B, severe
hepatitis B, chronic hepatitis B, compensated cirrhosis, decompensated
cirrhosis and primary liver cancer and estimated the costs as $2954, $10834,
$4552, $7400.28, $6936 and $10635, respectively. One limitation of this study is
that it looked only at one component of cost so will not give the total picture
of the economic burden of hepatitis B virus disease.(17)
This study therefore is aimed at estimating the financial burden
by quantifying the direct medical, direct non-medical and indirect costs of
managing patients with various stages of chronic hepatitis B virus
disease.The findings of this study will
provide evidence that will support ongoing universal coverage reforms in
Nigeria. It will also enable policymakers to support such patients with HBV and
perform informed budgeting. Furthermore, the findings will enable funding
agencies, program managers in government and non-governmental organisations to estimate how much it will require to help such patients (households) in Port Harcourt, Rivers
State as they plan for intervention.
METHODS
Study design
This was a descriptive cross-sectional survey that retrospectively collected data on
direct medical costs and interviewed patients on direct non-medical and indirect
costs. It was a health facility-based study where patients were assessed to the
household level.
Study Setting
Data was collected from adult HBV-infected patients receiving care
in two teaching hospitals Port Harcourt. This is because they are the only
facilities that have the manpower with requisite skills to manage hepatitis B
disease and receive referrals from all other health facilities in Port
Harcourt. Sample was collected over four months. Patients were clustered
according to clinic days they visited the hospital and through simple random
sampling, the number of clinic days required to produce the estimated minimum
sample size was selected. On the selected clinic day, all the patients that met
the inclusion criteria were included in the study. The data were collected with
a structured, close-ended, interviewer-administered questionnaire adapted from
a previous study [13].The cost was collected in naira and converted
to dollars at the rate of $1 = N380 [14].
Study participants
A two-stage sampling method was used to recruit 107 hepatitis B
patients at various stages of the disease. Stage 1 was a simple random sampling
with which 16 clinic days were selected by balloting while stage 2 involved a
systematic sampling to recruit the eligible patients for the study.
The inclusion criteria were patients on management for HBV that
have been on treatment for at least six months and those that have completed
treatment. Six months allowed for enough time for the treatment pattern to be
established and a patient can be completely treated and discharged within this
time [12]. Coinfected patients were excluded from the
study for ease of analysis and clarity in communicating the findings.
Variables
The variables measured in this study include the sociodemographic characteristics, direct medical cost,
direct non-medical cost and indirect cost.
Bias
Recall bias was a concern in this study seeing that respondents
needed to remember how much they spent on services accessed up to a three month
prior to the time. This was mitigated by verifying the services respondents
received within the period from their hospital folders and attaching their
known prices from hospital price list to reduce the impact of recall bias.
Study size
The sample size for this study was computed using the Cochran’s
formula for cross-sectional studies. Significance level of 95% (1.96), a
proportion of catastrophic expenditure in a previous study for hepatitis B of
50% (0.5), degree of freedom of 10% (0.1) and non-response of 10% (0.1), the
minimum sample size was estimated to be 107 HBV patients.
Statistical analysis
Data was analysed using Statistical
Package for Social Sciences version 25 and frequencies presented in form of
tables and charts.
Direct medical cost included the cost of consultation, drugs
(orthodox and alternative medicine), investigations and admission/hospital
stay. This cost was collected per month and extrapolated to a year. The cost of
all this, haven been collected as described above, was calculated as the direct
medical cost for the different stages of hepatitis B and C disease using the
formula below
Annual cost per patient = (Cost per visit X Visits per year) +
(Cost per admission X Admissions per year)
Where;
Cost per visit includes the total amount spent
on consultation, drugs, investigation on that particular visit.
Cost per admission includes the total amount
spent on medical services during an admission episode.
The use of charge for estimation of cost was considered the most
appropriate approach.(18)
The cost computation was done for an average of six visits per
year for hepatitis B
All costs are derived in naira and converted to the dollar
equivalent at the rate of $1 = N380.
Direct non-medical cost which includes the cost of travel
(transportation to and from the hospital), meals and accommodation where utilised was done using the same formula below.
Annual cost per patient = (Cost per visit X Visits per year) +
(Cost per admission X Admissions per year)
Indirect cost was estimated using the human capital approach, the
patient’s income prior to the illness was used to estimate his/her income loss
as a result of visiting the hospital. Each patient’s income was reduced to the
hour so it can be used for estimation. For those not working, productivity loss
was estimated assuming the patient’s income to be the minimum wage.
Time loss valuation (Human Capital Approach, not adjusting wages)
Indirect Cost = (tvisit x W)
+ (thospitalisation x W) + (ttravel x W) + (tpick
up drugs x W)
W is patient-reported pre-illness wage (from the survey), or wage
of the lowest paid unskilled government worker (minimum wage).
Estimation of guardian/companion cost
Cg = TFO + ICg
Where;
Cg = Guardian cost
TFO = Travel + Food + Other (including accommodation)
ICg= Guardian time loss
value
RESULTS
A total of 150 patients were approached for
this study with 135 completed responses giving a 90% response rate.
The household heads were almost all males, 91%
and only 9% were female. The average age of household heads was 48 years.
Majority of the household heads, 89%, were married. Almost two – thirds of the
household heads that participated in this study had tertiary education. They
engaged in different occupation, ranging from civil service to artisanal jobs,
some were professionals like engineers and teachers while others are retired.
There major sources of income were salary (45%) and business (49%). About 6% of
the patients’ household heads depended on welfare to pay for health care
services as seen in table 1.
Table 1;
Socio-Demographic Characteristics of Household Heads
Characteristics
Hepatitis B
Frequency (n=135)
Percentage
(%)
Sex
Male
123
91.1
Female
12
8.9
Age
Young (<30)
14
10.4
Middle age (31 – 60)
106
78.4
Elderly (>60)
15
11.1
Marital Status
Married
109
88.7
Currently Single
26
11.3
Education
No Education
5
3.7
Primary
5
3.7
Secondary
28
20.7
Tertiary
97
71.9
Occupation
Artisan
12
8.9
Business
58
43.0
Civil Servant
22
16.3
Farmer
6
4.4
Pensioner
6
4.4
Professional
27
20
Unemployed
4
3.0
Source of Income
Salary
61
45.2
Business Proceeds
66
48.9
Welfare
8
5.9
Table 2 illustrates the direct medical cost of managing viral hepatitis
B per patient per year (at an average of six visits per year) as derived from
this study is N345,613 (registration N2,062; consultation N5,022; drugs
N98,676; investigations N34,167, admission for an average stay of two weeks
N214,686). The patients who patronized Alternative medicine incurred an extra
mean expenditure of N205,000 in direct medical expense
per year.
Table
2. Direct Medical Cost of Managing Hepatitis B
Cost Variables
Hepatitis B
Mean
SD
Registration (Naira)
2,062
2,347
Consultation (Naira)
5,022
7,830
Drugs (Naira)
98,767
55,173
Investigations (Naira)
34,167
92,495
Admission (Naira)
107,343
110,643
Alt medicine (Naira)
205,000
48,744
SD – standard deviation
As seen in table 3, the direct Non-Medical Cost (Plus Patient
accompaniers cost) of managing Hepatitis B per patient per year (at an average
of six visits per year) is N50,446 per year
(Transportation; N2,698; Food N13,908; Accommodation N33,840).
Indirect cost of managing hepatitis B.
Table
3. Direct Non-Medical Cost of Managing Hepatitis B
Diagnosis
Transportation
Food
Accommodation
Hepatitis B
Mean
1366
4320
20500
Std. Deviation
779
6930
25300
Patients Accompanier’s Cost
Mean
1332
9588
13340
Std. Deviation
1624
16335
5780
The Indirect cost for managing Hep B in this study is N114,000
and patient accompaniers cost is N45,900 making a total of N159,900 per year
(at an average of six visits per year).
Figure 1 shows the various proportions of the
components on the total cost. Direct medical cost is 345, 613 (63%), direct
non-medical cost is 50,446 (9%) and indirect cost is 159,900 (28%) making a
total cost of N564,959
DISCUSSION
The findings of this study shows that the high
cost of managing viral hepatitis B can have significant public health
implications like reduced access to care, increased health disparities, deepen
catastrophic health expenditure and worsen disease transmission.
The high cost of managing hepatitis B combined
with the high out-of-pocket payment in this clime will inadvertently reduce
presentation at health facilities. Indigent patients will explore other cheaper
means of care even if they are they unwholesome because that is what they can
afford. This can lead to delays in diagnosis and treatment, which can increase
the risk of serious liver damage, liver cancer, and death. Lack of access to
care can also contribute to the spread of the virus, as people who are unaware
of their infection are more likely to transmit the virus to others. The high
cost can also contribute to health disparities with poor access amongst the
poor affecting disease prevalence and rate of spread.
Presenting the costs in the dollar equivalent at
an exchange rate of N380 to the dollar showed that the direct medical cost of
managing hepatitis B for a patient per year is ₦354,613 ($933). This
includes the cost of one-off registration, the cumulative cost of annual
consultation, which is usually paid for every clinic visit or review for
admission, cost of drugs and cost of investigations. Additionally, some
patients who patronised herbs and other forms of
alternative medicine spend an average of ₦205,000 ($540) per year as part
of their direct medical cost. The direct non-medical cost of managing hepatitis
B as derived from this study is ₦50,446 ($133) per patient per year and
this essentially covers costs for food, transportation and patient
accompanier’s cost. The indirect cost of managing hepatitis B in this study is ₦159,900
($421)per patient per year. This covers the cost
associated with the loss of resources due to morbidity and mortality. The total
cost of managing a chronic hepatitis B patient per year as derived from this
study is ₦564,959 ($1,487).
These amounts derived for the direct medical, direct
non-medical and indirect costs are lower than the amounts reported in similar
studies in Shangdong China in 2013(5) and
that reported in Greece in 2017 (6). Both studies were multi health facility-based
and the respondents were studied at household levels, much like this study.
However, this difference could be attributed to the different correlating
economic indices like inflation and exchange rate of those countries at the
time of the study. Also, the purchasing power parity (PPP) which is a
macroeconomic metric used to compare economic productivity and standard of
living between two countries, is significantly different between Nigeria, China
and Greece.
Specifically, the amount reported in this study
for the direct non-medical cost is equivalent to 9% of the total cost of
managing hepatitis B per patient per year. This value is the same as the upper
limit of 3 – 9% reported in Shangdong China in 2013
(5). The proportionate direct non-medical cost from both studies is similar
despite the differences in time and economic indices because it is reported in
proportions and not absolute numbers. This result also goes to show that the
direct non-medical cost is not a major part of the patient’s costs though it
cannot be ignored as it contributes to the total patient costs and could
determine if the patient will come to the facility to access care or not.
The indirect cost as seen from this study is
three times the direct non-medical cost. This finding agrees with the statement
by Henry Flood and Richard Phelps that the indirect medical cost though
difficult to estimate should never be overlooked (15). The relatively high
indirect cost could also point to the efficiency or lack of it, of the health
system in these hospitals. If the outpatients are efficiently attended to on
time, they will spend less time in the hospital and this will, in turn, drive
down their indirect cost which is a function of how much time they spend in the
hospital.
The amounts estimated for the management of
these conditions are quite meagre compared to the
actual amount needed to cover the treatment of these conditions. This study
focused mainly on the patient’s perspective of the cost of illness. This is
only the first step in trying to estimate the cost of illness. There is a need
for further research on the provider aspects, which will throw light on the
cost of providing the services for the patients. That aspect of the cost will
reveal the direct Government subsidies that are often seen in financing
healthcare in Nigeria. The cost from the patient perspective and that from the
provider perspective put together with Government spending will give the
societal perspective of the cost of illness.
This study also found that the total cost of managing a hepatitis
B patient for a period of one year is ₦564,959 ($1,487). Breaking these
figures down to the months, it will be ₦47,070 ($124) for hepatitis B.
Meaning that a hepatitis B patient who earns a minimum wage of ₦30,000 (($79)
a month will need more than a 100% of their monthly earning to treat their
condition for one month. This clearly shows that the cost is beyond such
patient’s reach if he has to pay out-of-pocket. This inability to cover the
cost constitutes a major setback in accessing healthcare and further worsens
the health indices from the region. For this patient to access healthcare as at
when needed, there needs to be a form of affordable pre-payment plan or the
cost is subsidised significantly.
The majority of the patients with chronic viral hepatitis have no
pre-payment plans as such pay out-of-pocket from their monthly salaries or from
their business proceeds. Some utilized previous savings to pay for health care
while the remaining depend on friends, relatives, sell their assets or take a
loan to pay for their treatment. These findings are similar to a study done in Bayelsa State, although that study was not facility-based
and looked at costs of managing any health condition in general. This means
that a good proportion of respondents have to wait for when salaries are paid
before, they can access treatment for their condition. That’s even for those
whose salaries can cover the cost. This could lead to delayed access to needed
healthcare services leading to poor compliance and sometimes worsening of
health condition and consequently increasing the cost of care. A reasonable
proportion of study participants also have to pull money from their business
proceeds to pay for healthcare. This adversely affects the fortune of such
businesses and unfavourably impact on their growth.
Almost all of the respondents reported that paying for their
treatment, partially or absolutely affected their ability to make other
household expenditure. This further buttresses the fact that management of
these conditions is expensive and constitutes a financial burden to the
household92.
There is therefore a need to introduce health financing schemes to
remove the burden of payment for treatment of hepatitis B at the point of
service delivery, from the patients, in line with universal health coverage
reforms.
CONCLUSION
This study revealed that the treatment of hepatitis B is expensive
considering the income profile of the patients. The average amount needed to
treat this condition is more than the minimum wage of the average patient. There is therefore the
need for innovative financing plans including waivers, and subsidies for
persons living with Hepatitis B in resource-poor regions of the world.
One of the concepts of universal health coverage emphasizes the
range of health services provided. There is a need to expand the coverage of
donor funding for long-term communicable diseases like HIV and tuberculosis to
include hepatitis B. The incidence of these conditions has been greatly reduced
directly because of the activities of donor agencies.
Other methods of reducing the burden of payment for healthcare by
hepatitis patients will be to increase the uptake of health insurance among
these patients as well as establish pre-payment mechanisms that can reduce the
need to pay out-of-pocket for their treatment. States and Local Governments can
institute a conditional cash transfer scheme that refunds the patients every
expense on transportation and food while receiving treatment. This can also
cover for the patients’ accompanier as well. This will go a long way to ease
the burden arising from direct non-medical cost and encourage compliance with
the treatment schedule.
Non-Governmental Organisations should
consider funding the treatment of hepatitis B seeing that the exact costs of
managing these conditions can be computed, budgeted for and funded. This
recommendation is on the finding that funding attention had not been adequately
channeled toward hepatitis B because the costs of managing these conditions had
not been clearly estimated.
The cost estimates of this study were from the patient’s
perspective and it would be needful for future studies to determine the provider
perspective of the cost of managing hepatitis B and explore possible wastes in
the management of such patients. With these findings determined and the
prevalence of hepatitis B also studied and reported, the exact amount required
to manage these conditions per year can be determined to aid planning and
budgetary allocation for health.
Limitations of the study
The limitations of this study include potential recall bias in
retrieving retrospective data on income and expenditure estimates but this was
mitigated by limiting such data to 1 month, verifying the services respondents
received within the period from their medical records in the hospital and
comparing cost of services/products with known prices from hospital price list
to reduce the impact of recall bias. Another limitation was the sample size for
the study. Hepatitis B is not as prevalent as other long-term conditions like
HIV or Tuberculosis. However, the minimum sample size required for this study
was met within a reasonable time for the study. Subsequent studies will benefit
from the recruitment of patient over a longer period of time to recruit as many
respondents as possible to the study.
Acknowledgement
We
are grateful to the staff and patients of the Department of Internal Medicine at
the University of Port Harcourt Teaching Hospital and the Rivers State
University Teaching Hospital for their cooperation during the period of data
collection.
Authors’ contributions
AAA
and DSO were involved in the conceptualization, planning and implementation of
the study. Data collection team was headed by AAA. AD reviewed the
questionnaire and aided data collection. All authors contributed to the
interpretation of the results and read and approved the final manuscript.
Conflict of Interest:
None declared
Grant for Study: no
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Cite this
Article: Alali, AA;
Dan-Jumbo, A; Ogaji, DS (2023). Cost of Managing Chronic
Hepatitis B in a Resource-Poor Setting; The Implications for Universal Health
Coverage Reform. Greener Journal of
Medical Sciences, 13(2): 155-163, https://doi.org/10.5281/zenodo.8332533.
