Cancer Care in Nigeria: A Call to Action
Cancer is one of the leading causes of death globally, accounting for almost 10 million deaths in 2020 alone. Approximately 70% of these deaths occurred in low- and middle-income countries. In Nigeria, cancer was responsible for nearly 80,000 deaths in 2020.
This high cancer disease burden is coupled with the significant out-of-pocket healthcare spending in the country - the majority of Nigerian cancer patients pay for their care without financial support. Evidently, the National Health Insurance Scheme (NHIS) has a huge gap to fill in terms of providing adequate coverage for cancer treatments. Unfortunately, the gap still remains and access to cancer treatment has been limited in the country. While other countries are providing access to the latest innovative cancer drugs and personalized medicine via public insurance schemes, Nigerian patients still struggle to access basic chemotherapy.
There are several factors that are driving such limited access to cancer treatments in the country, but two key drivers are at the top of the list: the lack of cancer coverage through the NHIS and the significant pharmaceutical supply chain issues.
Lack of NHIS Cancer Coverage
While the Nigerian government has made significant investments to increase the number of cancer treatment facilities and improve existing facilities across the country, Nigerian patients struggle to afford the cancer treatments offered at these hospitals because the NHIS does not cover cancer care.
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An evaluation of the NHIS benefits package from October 2020 revealed that cancer care is not listed as part of the benefits offered by the scheme. Additionally, CT and MRI scans - diagnostic tests that are crucial to identifying most cancers - are only partially covered by the NHIS. This lack of national insurance coverage for cancer care means the majority of Nigerian cancer patients pay for their care out-of-pocket - one study estimated that 72% of breast cancer patients in Nigeria pay for their treatment out-of-pocket. This figure is even bleaker considering that breast cancer has the highest mortality rate among cancers in the Nigerian population.
NHIS representatives have frequently cited the immense budget impact that cancer care coverage would entail and the limited funds available to cover other high prevalence, communicable diseases in the country as key factors for the partial or total exclusion of cancer care on the scheme. However, as the scheme grows, representatives are hopeful that coverage will be extended to cancer. Managing limited budgets and evaluating which diseases and drugs to cover are major dilemmas that national health insurance officials face across the globe. However, when compared to other Sub-Saharan African countries, out-of-pocket payment for cancer care in Nigeria is significantly higher. The same study estimated that 45% of Ghanian and just 8% of Kenyan breast cancer patients pay out-of-pocket for their care, even though all three countries have a similar GDP per capita.
The Ghana NHIS, which launched around the same time as Nigeria’s NHIS, covers cancer treatment for breast and cervical cancer treatment, while treatments for other cancer types are excluded. Ghanaian NHIS officials likely limited cancer coverage in this way because breast and cervical cancer have the highest mortality rates among cancers in the Ghanaian population. The Kenyan National Hospital Insurance Fund (NHIF), established in 1966, offers cancer treatment under their different plans (including the NHIF SUPA plan, Kenya’s largest plan, as well as their Civil Servants Scheme). Cancer treatment covered under the plans ranges from diagnostics, radiotherapy, basic and complex chemotherapy, and specialized surgery. Additionally, the Kenyan Ministry of Health’s essential medicines list includes a wide variety of cancer drugs that treat both solid tumors (e.g., breast, prostate, lung, etc.) as well as hematological cancers (e.g., leukemia, multiple myeloma, lymphoma, etc.), including innovative personalized medicine.
Pharmaceutical Supply Chain Issues
The pharmaceutical supply chain simply refers to the network through which prescription medicines are manufactured and delivered to patients. The pharmaceutical supply chain involves several stakeholders, including pharmaceutical manufacturers, wholesale distributors, and hospital and retail pharmacies. The process is often complex, and the specific situation in Nigeria is no different.
Before manufactured drugs actually get to Nigerian patients, they have to go through several levels of distribution, including the main distributor and several sub-distributors. At each step in the supply chain, distributors can add markups of up to 10% onto the cost of the drugs. Additionally, as most pharmaceutical manufacturers import drugs into Nigeria via third-party distributors, costs are often inflated given the foreign exchange issues with the Naira. At the last step in the supply chain, when hospital pharmacies are out of stock of prescription drugs, patients are often diverted to retail pharmacies in the private sector, where markups along the supply chain are even more pronounced. Lastly, there are concerns regarding the quality of drugs given poor cold chain infrastructure (an issue that is a key concern of Nigeria’s national COVID-19 vaccine rollout).
As a result of these supply chain issues, the cost to patients is often astronomical and the quality of the drugs is uncertain - huge barriers when out-of-pocket payments represent over 70% of Nigeria’s current health expenditure.
So what is being done to improve access to cancer care?
Several initiatives are underway to improve access to cancer treatment in Nigeria, mostly spearheaded by the Nigerian Ministry of Health.
Public-private partnerships (PPPs) with pharmaceutical manufacturers and other private healthcare companies have been one of the key initiatives to bridge the gap in cancer care access in the country. For example, in October 2019, the Nigerian Federal Ministry of Health launched the Chemotherapy Access Partnership with Pfizer, Inc., the Clinton Health Access Initiative, Inc., the American Cancer Society, Worldwide Healthcare, and EMGE Resources, Limited. The goal of this PPP is to deliver chemotherapy to seven teaching hospitals throughout the country, helping Nigerian patients save up to 50% of their treatment costs and enabling thousands of additional patients to access care.
The seven teaching hospitals participating in the Chemotherapy Access Partnership include Ahmadu Bello University Teaching Hospital, Aminu Kano Teaching Hospital, Lagos University Teaching Hospital, National Hospital Abuja, Obafemi Awolowo University Teaching Hospital, University College Hospital Ibadan, and University of Nigeria Teaching Hospital Enugu.
In addition to improving access to cancer treatments for Nigerian patients, this PPP also aims to fix supply chain hurdles. Participating pharmaceutical companies and drug distributors will receive immediate payment under the partnership to keep the program sustainable and drug stocks replenished. Additionally, according to the Clinton Health Access Initiative, Inc., the program aims to reduce the astronomical out-of-pocket payments for Nigerian patients by reducing complexity in the distribution process, stabilizing prices, coordinating orders, streamlining registration of regulatory-approved products, and promoting the entry of international suppliers with a range of quality-assured products.
Another important PPP in cancer care was between Roche Products Nigeria and the federal and state ministries of health in 2017. As part of several efforts to improve access and alleviate supply chain issues in cancer care, Roche successfully convinced state governments to pay for breast cancer treatments, leading to an initial agreement to pay for 20 patients over five years. Following the success at the state level, Roche began discussions with the federal government to create a fund for critical illness, including cancer; as a result, the number of patients able to access Roche’s modern drugs increased by over 300% between 2016 (105 patients) and 2018 (431 patients).
Another key initiative to bridge the gap in cancer care access in the country is the Federal Ministry of Health’s 2018-2022 National Cancer Control Plan (NCCP). With a budget of over $309 million, the NCCP’s mission is to reduce exposure to risk factors of cancer and to establish a framework to ensure access to cancer screening, care, and improved quality of life for cancer patients. As part of their governance and finance goals, one of the planned activities of the NCCP is to provide financial protection for cancer patients through the reimbursement of cancer care by the NHIS. However, this plan is contingent on the MoH’s ability to divert enough budget and government resources to the NHIS in order to allow expanded coverage to cancer care for Nigerian patients.
Other public sector initiatives are underway to improve access to cancer care. The NHDIC initiated a patient access program to cover the cost of care for patients at the recently commissioned NSIA-LUTH Cancer Center (NLCC) in Lagos. “The problem of who pays for care is always there, and the worst part of it is that it’s out of pocket. Only 4% of Nigerians are insured. Unfortunately, the insurance doesn't cover things like cancer.” said Dr. Tolulope Adewole, CEO of the NHDIC, at the TC Health panel discussion on October 3rd, 2021. “At the NHDIC cancer center in Lagos, we started a program called the NLCC Indigent Support program, whereby 1% of our revenue of the previous month goes into the notional treatment of patients who are certified to be indigent so they can actually get some level of care and don't have to have cancer as a death sentence.”
Key Takeaways from TC Health: Improving access to cancer care and other critical illnesses should be a key priority of the Nigerian Ministry of Health and the NHIS given the growing burden of disease in the country. The main way to achieve this is to allocate more of the federal and state budgets to the NHIS in order to allow the NHIS to feasibly expand coverage to expensive cancer treatments. Alongside these efforts, the government can also push forward PPPs and patient access schemes to bridge the gap in access for Nigerian patients who cannot afford to pay for cancer treatment out-of-pocket. To curb exorbitant markups on the drugs that patients receive, nuanced pharmaceutical supply chain policies need to be enacted to regulate drug quality management and price/distributor markups along the supply chain without disincentivizing supply chain stakeholders.
