Economic Pulse Check: Unmasking the Financial Strain of Cardiovascular Disease in Africa
Cardiovascular diseases (CVD) such as heart failure, cardiomyopathies, and coronary artery disease are increasing rapidly in Nigeria and sub-Saharan Africa, with high blood pressure affecting up to 40% of adults in some Nigerian regions. This growing health challenge, exacerbated by inadequate treatment, is especially concerning in a region that has long struggled to manage infectious diseases since the establishment of its healthcare systems. The increasing prevalence of cardiovascular disease presents a distinct challenge for the region, and the economic repercussions of CVD are now becoming apparent to both the healthcare systems and the population.
At the individual patient and household level, cardiovascular disease (CVD) significantly influences household expenditure in Sub-Saharan Africa. This is evident in countries like Ghana and South Africa, where households that are affected by CVD allocate a higher proportion of their spending to medical expenses, leading to an increased likelihood of catastrophic health expenditure (CHE). Specifically, in Ghana, households with CVD are two to four times more likely to incur CHE, while in South Africa, the presence of CVD triples the likelihood of facing financial challenges related to health expenses compared to households without CVD.
With the catastrophic costs of CVD for patients, evidence suggests that maintaining patients on guideline-directed therapy is challenging, with frequent requests for cheaper options. This situation results in suboptimal treatment, suboptimal compliance with treatment, and a subsequent rise in CVD-related hospitalisations in Africa, directly adding a significant cost burden on healthcare systems.
While data on the economic consequences of CVD in Sub-Saharan Africa are scarce, there is compelling evidence suggesting that the cost of managing critical cardiovascular events such as stroke, heart failure and hypertensive emergencies has the potential to reach catastrophic levels for the region's health systems if not effectively addressed.
The economic burden of heart failure (HF) in Nigeria is substantial, as revealed by data from a prospective HF registry in a tertiary hospital in Abeokuta, southwest Nigeria. The study, focusing on a cohort of 239 HF cases over 12 months, found a total cost of care amounting to over ₦76 million (equivalent to US$508,595 in 2014), averaging ₦319,200 (US$2,128 in 2014) per patient annually. With the average monthly income in Nigeria ranging between N85,700 (US$210) and N1.5 million (US$3,700), and 63% of the population living below the poverty line, these costs are completely unaffordable for most of the population. Inpatient care constituted a significant proportion (46%) of the healthcare expenditure, totalling almost ₦35 million (~US$301,230 in 2014). Outpatient costs, driven mainly by transportation expenses for monthly follow-up visits, were estimated at ₦41 million (US$275,282 in 2014). Extrapolating these figures to the national level suggests a considerable economic burden associated with CVD in Nigeria.
In South Africa, approximately 2% to 3% of the country’s gross national income, or roughly 25% of healthcare expenditures, was devoted to treating CVD. More broadly, several studies indicate a growing trend of CVD admissions relative to total hospital admissions in Sub-Saharan Africa. Notably, hospitals in Nigeria, Ethiopia, Ghana, and Tanzania have experienced a significant increase in CVD admissions over the past two decades.
Addressing the escalating economic impact of CVD necessitates exploring solutions at the government, hospital, and HMO/insurance levels. So what can be done?
At the national government level, a cost-effectiveness model study sheds light on how to tackle cardiovascular disease (CVD) in Sub-Saharan Africa and Southeast Asia, considering both individual and population health. For individuals at higher risk, interventions like managing acute cardiovascular events prove most effective, while on a broader scale, strategies targeting larger, lower-risk groups, such as health promotion and prevention, have significant overall health benefits. By combining approaches that focus on both individuals and the wider population and at a cost of less than the GDP per capita of the region, the study found that over 5000 health-related issues per million people can be prevented every year. The cost-effectiveness analysis suggests that many of these budget-friendly approaches should be prioritised for widespread implementation.
Nigerian hospitals grappling with the increasing number of cardiovascular patients can draw valuable lessons from the success of Narayana Hrudayalaya Hospital in India. With similar volume and cost challenges, Narayana adopted a lean and standardised approach to healthcare service delivery. Dr Devi Shetty, renowned for his cardiac surgeries, emphasised fixed salaries for doctors tied to increased surgical output, high patient volumes, and stringent cost monitoring. Narayana's focus on partnerships, innovative cost-cutting measures, and expansion into tier 2 cities contributed to its ability to offer cardiac care at nearly 40% of the cost of other private hospitals. Nigerian hospitals can explore similar strategies to optimise efficiency, reduce costs, and cater to the growing demand for cardiovascular healthcare.
As relying solely on self-financing healthcare proves impractical and unaffordable for the average Nigerian and African, promoting the adoption of health insurance becomes crucial. Closing the current coverage gap requires political dedication and sustainable financing strategies. This involves exploring alternative approaches to coverage and implementing personalised risk-management mechanisms through private insurers.
Like many Sub-Saharan African countries, Nigeria faces significant challenges in terms of healthcare infrastructure and access to specialised medical services. Nonetheless, expanding patient access to cardiology care in Nigeria can be achieved through various means, including HMOs and insurance. Enrolled patients can benefit from financial coverage of cardiology services, thereby reducing the financial burden on patients and encouraging timely medical attention. An alternative strategy involves prioritising preventive care and early intervention, as insurance plans often provide incentives for these practices. Regular checkups, screenings, and early detection of risk factors play a pivotal role in preventing the progression of heart disease.
Several organisations in the country are actively working to broaden access to cardiology services. Notably, Iwosan Lagoon Hospitals has taken proactive steps to enhance access through their recently established Centre of Excellence for Cardiac Care & Cardiac Surgery by offering comprehensive packages that include various interventional cardiology and interventional radiology procedures, as well as non-invasive tests such as echocardiograms. In Sub-Saharan Africa, where the confirmation of cardiovascular disease (CVD) primarily relies on echocardiograms (among other diagnostic tests), the introduction of portable echocardiography provides an opportunity to identify CVD patients earlier, enabling preventive measures that can result in significant cost savings for both the healthcare system and patients. These packages are designed for and offered to HMOs/insurance plans to expand coverage to their members/enrollees. By bundling healthcare services, Iwosan provides multiple services at a budget-friendly price to their HMO/insurance partners, allowing affordable access to cardiology services for patients.
Key Takeaways from TC Health: In confronting the rising tide of cardiovascular diseases (CVD) in Nigeria and sub-Saharan Africa, urgent action is imperative. Governments must prioritise cost-effective strategies targeting both high-risk individuals and broader populations. Emulating successful models in similar countries like India can guide Nigerian hospitals toward lean, efficient, and cost-effective cardiac care. Crucially, shifting from self-financing to widespread health insurance adoption is vital, demanding political commitment and sustainable financing strategies. The focus should be on innovative coverage approaches and personalised risk-management mechanisms through private insurers. This collective effort is essential for mitigating the economic burden of CVD and ensuring accessible, affordable, and effective cardiac care for all.
