The Financial Burden of Non-Communicable Chronic Diseases in Rural Nigeria: Wealth and Gender Heterogeneity in Health Care Utilization and Health Expenditures.
OBJECTIVE
Better insights into health care utilization and out-of-pocket expenditures for non-communicable chronic diseases (NCCD) are needed to develop accessible health care and limit the increasing financial burden of NCCDs in Sub-Saharan Africa.


METHODS
A household survey was conducted in rural Kwara State, Nigeria, among 5,761 individuals. Data were obtained using biomedical and socio-economic questionnaires. Health care utilization, NCCD-related health expenditures and distances to health care providers were compared by sex and by wealth quintile, and a Heckman regression model was used to estimate health expenditures taking selection bias in health care utilization into account.


RESULTS
The prevalence of NCCDs in our sample was 6.2%. NCCD-affected individuals from the wealthiest quintile utilized formal health care nearly twice as often as those from the lowest quintile (87.8% vs 46.2%, p = 0.002). Women reported foregone formal care more often than men (43.5% vs. 27.0%, p = 0.058). Health expenditures relative to annual consumption of the poorest quintile exceeded those of the highest quintile 2.2-fold, and the poorest quintile exhibited a higher rate of catastrophic health spending (10.8% among NCCD-affected households) than the three upper quintiles (4.2% to 6.7%). Long travel distances to the nearest provider, highest for the poorest quintile, were a significant deterrent to seeking care. Using distance to the nearest facility as instrument to account for selection into health care utilization, we estimated out-of-pocket health care expenditures for NCCDs to be significantly higher in the lowest wealth quintile compared to the three upper quintiles.


CONCLUSIONS
Facing potentially high health care costs and poor accessibility of health care facilities, many individuals suffering from NCCDs-particularly women and the poor-forego formal care, thereby increasing the risk of more severe illness in the future. When seeking care, the poor spend less on treatment than the rich, suggestive of lower quality care, while their expenditures represent a higher share of their annual household consumption. This calls for targeted interventions that enhance health care accessibility and provide financial protection from the consequences of NCCDs, especially for vulnerable populations.
Faculty of Economics, VU University, Amsterdam, The Netherlands.|Tinbergen Institute, Amsterdam, The Netherlands.|Amsterdam Institute for International Development, Amsterdam, The Netherlands.
Wendy
W
Janssens
Faculty of Economics and Business, KU Leuven, Campus Brussel, Brussels, Belgium.|School of Business and Law, University of Agder, Kristiansand, Norway.
Jann
http://orcid.org/0000-0002-2288-8464
J
Goedecke
PharmAccess Foundation, Amsterdam, The Netherlands.|Center for Tropical and Travel Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Godelieve J
GJ
de Bree
Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
Sunday A
SA
Aderibigbe
Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
Tanimola M
TM
Akande
City University London, London, United Kingdom.|Institute for Fiscal Studies, London, United Kingdom.|CEPR and Center for Global Development, London, United Kingdom.
Alice
A
Mesnard
D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease / Q000191:economics* / Q000453:epidemiology; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D005191:Family Characteristics; D005260:Female; D005382:Financing, Personal / Q000191:economics*; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009549:Nigeria / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D015995:Prevalence; D012424:Rural Population / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D055815:Young Adult