The Nigerian government's decision to provide antiretrovirals freely as part of HIV programmes at the country's health facilities has dramatically improved the uptake of treatment.
But this has not been enough to eliminate the high and sometimes inequitable economic burden of HIV/AIDS on households. Exorbitant food and transport costs, as well as the costs of illnesses linked to HIV, hinder full access to treatment services. Households end up having to fork out money they don't necessarily have.
In our study we looked at health care costs in three Nigerian states: Adamawa in northern Nigeria, and Akwa Ibom and Anambra in southern Nigeria.
The financial burden of HIV/AIDS
The Nigerian health system is organised into three levels: tertiary, which is primarily a responsibility of the federal government; secondary, which state governments look after; and primary, which is the responsibility of local governments. Health services are provided by both the public and private sectors.
Out-of-pocket health expenditure places a financial burden on households. Where these costs exceed a particular income level, households will either not use health services or they will be forced to sacrifice other items that are essential to their well-being, like education. They become poorer and may be pushed into a lower socio-economic bracket. In re-ranking, some people become poor, whilst some are pushed into deeper poverty.
In our study, we considered two scenarios: one in which households spent more than 40% of their non-food budget on health expenses, and one in which they spent more than 10%.
We found that up to 95% of household are forced to sacrifice other basic needs, sell assets or incur debt to pay for inpatient care for someone living with HIV in their homes. And at least 8% are put in the same position to cover outpatient costs. On average, Nigerian patients spend US$6.10 for every outpatient visit and and US$92.3 for every inpatient stay.
More than 48.4% of Nigerians live below the poverty line, according to the World Bank's 2013 indicators. Most spend all their money on food. Any other expenses are considered to have a detrimental effect on the household's welfare.
In addition, because HIV/AIDS increases a person's vulnerability to other illnesses, patients often get opportunistic infections. As a result they incur other expenses like non-antiretroviral drugs, non-routine tests, medical consultations, transportation, food and hospital stays. These are seldom covered by any risk-pooling mechanism or government programme.
The situation in Nigeria
In Adamawa state, which has a population of 3.1 million people, there is an HIV prevalence of 3.8%. In Akwa Ibom, where 3.9 million people live, there is a prevalence rate of 10.9% and in Anambra state there is a prevalence rate of 8.7% for a population of 4.1 million people.
At all the sites that formed part of our study, antiretroviral therapy was fully subsidised by the government and development partners.
In Anambra state, treatment for opportunistic infections was fully subsidised. In Adamawa, some facilities received fully subsidised treatment for opportunistic infections. But in Akwa Ibom, all patients were routinely charged a fee for treating such infections. In all cases, patients were still expected to pay for their laboratory tests and other incidental expenditures on co-morbidity.
We found that in Anambra, where the treatment for opportunistic infections was subsidised, close to 80% of the respondents were treated for opportunistic infections. But in Akwa Ibom, where patients were charged, only 25% accessed such treatment. In Adamawa, where only some opportunistic infection treatments were subsidised, 45% accessed treatment.
The cost of accessing treatment
In many low- and middle-income countries, there is little evidence of the economic burden that accessing treatment for HIV/AIDS causes to patients and their households. Nigeria is one of these countries.
Previous research has found that in developing countries, 91% of patients paid for transport to attend antiretroviral clinics and 60% of patients purchased non-prescription medicines or special food at considerable personal cost.
Our study found that these costs affect people differently. Those who lived in rural areas and those with lower socio-economic standing pay more to access antiretroviral treatment. Rural populations have to travel further to reach clinics, which increases the cost burden of travel; they also have to wait longer to see medical personnel, which means they incur additional food costs.
To address this inequality, interventions need a layered approach to the problems that are impoverishing people living with HIV/AIDS.
To tackle the problem, policy interventions need to focus on two areas. These are spreading treatment centres so that they are nearer to people and deploying more health personnel to these centres. Combined, these two initiatives will:
reduce travel expenses;
improve adherence to treatment; and
reduce the need to spend extended periods at treatment facilities, which results in people spending money on food.
Financial risk-protection mechanisms should also be implemented to significantly remove the expenses that people living with HIV/AIDS and their households have to incur to receive antiretroviral services. Subsidising transport expenses in the form of vouchers or reimbursement systems are good financial protection mechanisms. And enhancing the income of people living with HIV and their households can also reduce their expenses.
But, ultimately, universal financial risk protection within the sphere of universal health coverage should be the ultimate goal of HIV/AIDS treatment services. This will protect all households against the occurrence of catastrophic health expenses to access the necessary treatment.
Obinna Onwujekwe receives funding from FHI360, World Health Organisation, World Bank,