TABLE OF CONTENTS

Title page                                                                                                                    i

Approval page                                                                                                             ii

Certification                                                                                                                iii

Dedication                                                                                                                  iv

Acknowledgement                                                                                                      v

Table of contents                                                                                                        vi

List of tables                                                                                                               vii

Abstract                                                                                                                      viii

CHAPTER ONE: INTRODUCTION

Background to the Study                                                                                           1

Statement of the Problem                                                                  4

Purpose of the Study                                                                                                  5

Objectives of the Study                                                                                              5

Research Hypothesis                                                                                                   5

Significance of the Study                                                                                           6

Scope of the Study                                                                                                     7

Operational Definition of Terms                                                            7

CHAPTER TWO: LITERATURE REVIEW

Concept of Diabetes Mellitus                                                                    9

Types of Diabetes Mellitus                                                                     10

Risk Factors/causes of Diabetes                                                               12

Diagnosis of Diabetes Mellitus                                                                14

Management of Diabetes                                                                             17

Concept of Catastrophic Health Expenditure                                     22

Catastrophic Health Expenditure in Nigeria                                      29

Payment Strategies in Healthcare                                                             30

Payment Coping Mechanism                                                                37

Conceptual Framework for the Study                                                        41

Empirical Review                                                                              45

Summary of reviewed Literature                                                          56

CHAPTER 3: RESEARCH METHOD

Research Design                                                                                                         58

Area of Study                                                                                                             58

Target Population                                                                                   59

Sample                                                                                                        59

Inclusion Criteria                                                                                 60

Sampling Procedure                                                                        60

Instrument for Data Collection                                                              60

Validity of Instrument                                                                            61

Reliability of the Instrument                                                                         62

Ethical Consideration                                                                          62

Procedure for Data Collection                                                                62

Method of Data Analysis                                                                       63

CHAPTER FOUR: PRESENTAION OF RESULT

Summary of Findings                                                                               85

CHAPTER FIVE: DISCUSSION OF FINDINGS

Discussion of Findings                                                                                  87

Conclusion                                                                                           101

Implication of the Findings                                                                     102

Recommendations                                                                                  102

Summary                                                                                                      104

Limitations of the Study                                                                          106

Suggestions for further Studies                                                             108

References                                                                                               110

Appendices                                                                                              119

Appendix I- The questionnaire                                                                      120

Appendix II- Ethical clearance                                                                   128

Appendix III- Patient informed consent form                                        129

                                             LIST OF TABLE

Table 1: Demographic Characteristics of Respondents.                  65

Table 2:   Length of DM Treatment and Frequency of checkup at FMC Umuahia.             66

Table 3:   Direct Cost of DM per Month Reflecting Unit Costs.       67

Table 4:  Sources of Income of Respondents.                                      68

Table 5: Respondent is Earning from income Source and their Earnings per hour               68

Table 6: Number of Days Respondents were Absent from work in a Month because of DM    (Mean SD)                                                     69         

Table 7: Employment status of person accompanying respondents to treatment venues     69

Table 8: Indirect cost of DM care.                                                 70         

Table 9:  Respondents’ monthly expenditure in Naira and mean catastrophic DM cost at 40%   threshold.                                   72

Table10: Household socioeconomic status of respondents.                    73

Table 11: Respondents expenditure per month by socioeconomic status (SD) and Catastrophic expenditure                                            74

Table 12: Payment strategies used by respondents.                           76

Table 13: Payment coping mechanisms used by respondents.   77

Table 14: The difference between SES and catastrophic DM expenditure 78

Table 15: The difference between socio-economic status of the respondents and the Payment strategies used.                                                      80

Table16: The difference between socioeconomic status of respondents and

Payment coping mechanism                                                                                  82

Table 17: Respondents report of level of ease/difficulty experienced in payment for Diabetic management.                                                                                           84

Table 18: Respondent’s suggestions on ways to be assisted to cope with DM treatment.          84                                                                                                  

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 productivity losses.

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