COMPARATIVE COST EFFECTIVENESS IF INTERVENTIONS TO CONTROL NON-COMMUNICABLE DISEASES (NCD) IN NIGERIA
The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries, including Kenya, disproportionately to the rest of the world. Our objective was to quantify patient payments to obtain NCD screening, diagnosis, and treatment services in the public and private sector in Kenya and evaluate patients’ ability to pay for the services.
Methods and findings
We collected payment data on cardiovascular diseases, diabetes, breast and cervical cancer, and respiratory diseases from Kenyatta National Hospital, the main tertiary public hospital, and the Kibera South Health Center—a public outpatient facility, and private sector practitioners and hospitals. We developed detailed treatment frameworks for each NCD and used an itemization cost approach to estimate payments. Patient affordability metrics were derived from Kenyan government surveys and national datasets.
Results compare public and private costs in U.S. dollars. NCD screening costs ranged from $4 to $36, while diagnostic procedures, particularly for breast and cervical cancer, were substantially more expensive. Annual hypertension medication costs ranged from $26 to $234 and $418 to $987 in public and private facilities, respectively. Stroke admissions ($1,874 versus $16,711) and dialysis for chronic kidney disease ($5,338 versus $11,024) were among the most expensive treatments. Cervical and breast cancer treatment cost for stage III (curative approach) was about $1,500 in public facilities and more than $7,500 in the private facilities. A large proportion of Kenyans aged 15 to 49 years do not have health insurance, which makes NCD services unaffordable for most people given the overall high cost of services relative to income (average household expenditure per adult is $413 per annum).
There is substantial variation in patient costs between the public and private sectors. Most NCD diagnosis and treatment costs, even in the public sector, represent a substantial economic burden that can result in catastrophic expenditures.
The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries (LMICs) disproportionate to the rest of the world. Currently, NCDs cause over 36 million annual deaths globally; 14 million of these are premature mortality (among those younger than 70 years), and 90% of these premature deaths occur in LMICs . Cancer, cardiovascular disease, respiratory disease, and diabetes are the major causes of NCD deaths in LMICs .
In Kenya, the mortality and morbidity from NCDs is rapidly increasing . Cardiovascular diseases are the leading cause of NCD mortality in Kenya because of the high prevalence of multiple risk factors, including hypertension, diabetes, cholesterol, smoking, and obesity . Multiple studies performed in selected populations across Kenya have identified a high prevalence of hypertension [4–6]. In the first nationally representative survey, performed in 2015 and which included hypertension measurement , hypertension was identified in 23.8% of the respondents aged 18 to 69 years and 7% of those not on medication were diagnosed with severe hypertension. Among those aged 18 to 44 years, 10.4% had three or more risk factors for cardiovascular disease, and among those aged 45 to 69 years, 25.9% had three or more risk factors.
Cancer is the second leading cause of NCD mortality, and the incidence of cancer increased from 28,000 to 41,000 between 2008 and 2012 [8, 9]. The three leading cancer sites are the cervix (40.1 cases per 100,000 individuals), the breast (38.3 cases per 100,000 individuals), and the prostate (31.6 cases per 100,000 individuals) . It is observed that most cancer cases are diagnosed at an advanced stage when curative treatment options are limited . There is sparse prevalence data on respiratory diseases—asthma and chronic obstructive pulmonary disease (COPD). A systematic analysis estimated the prevalence of asthma in Africa as 12.8% (95% confidence interval 8.2–17.1) in 2010 .
In response to the escalating burden of NCDs in Kenya, the government has established an NCD division within the Ministry of Health. Kenya also launched a 5-year National NCD Strategy in 2015 to guide the implementation of interventions to reduce the mortality from NCDs. To operationalize this strategy, it is important to understand the cost of NCD health services along the continuum of care, including those related to screening, diagnosis, and treatment. Knowledge on the costs of NCD management is needed to identify cost-effective solutions and prioritize interventions to address NCDs. Additionally, it is critically important to assess affordability of NCD services to evaluate patient access to required care. Individuals are required to pay for health care services in the public sector in Kenya; the payments are subsidized, but nevertheless, all services require some level of patient payments. Approximately half of all the health facilities in Kenya are managed by either private for-profit or not-for-profit organizations; therefore, a substantial proportion of health care is obtained in the private sector . A minority if individuals in Kenya have health insurance coverage and almost all employees in the formal sector, which is less than one-fifth of those employed, are covered through the National Hospital Insurance Fund (NHIF). The NHIF provides payments for specific inpatient and outpatient services but not all costs in the private sector are covered and therefore patients still incur out-of-pocket payments for health services. 
The objective of this study was to quantify patient payments for NCD screening, diagnosis, and treatment services in the public and private sector in Kenya and evaluate patients’ ability to pay for services along the continuum of care. We focused on the high-burden NCDs and their risk factors, and we included cardiovascular diseases, diabetes, breast and cervical cancer, and respiratory diseases in the assessment. These are the high prevalence diseases that the World Health Organization is targeting to achieve a 25% relative reduction in the overall NCD mortality by 2025
We performed a comprehensive assessment of patient payments related to the four targeted NCDs—cardiovascular disease, cancer, diabetes, and respiratory disease—we created a matrix of relevant clinical services along the continuum of care of each disease or key risk factor. We focused on risk factors and disease groupings for which there were comprehensive guidelines for early detection and management. An additional key consideration was inclusion of the risk factors and disease groups targeted in Kenya’s NCD strategic planning documents, including the Kenya Health Policy 2014–2030 , the Kenya National Strategy for the Prevention and Control of Non-Communicable Diseases 2015–2020  and the National Cancer Control Strategy 2011–2016 . Table 1 provides a summary of the health services included in this study.