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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 11  |  Page : 1-7

Should glaucoma be public funded in Nigeria? Background, justification, and the study overview


Department of Ophthalmology, College of Health Sciences, University of Abuja, Abuja, Nigeria

Date of Web Publication3-Jul-2018

Correspondence Address:
Abdulkabir Ayansiji Ayanniyi
Department of Ophthalmology, College of Health Sciences, University of Abuja, Abuja
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nnjcr.nnjcr_21_17

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  Abstract 


Many Nigeria's individuals with glaucoma are losing vision because they cannot afford glaucoma treatment. A work, “Should glaucoma be public funded in Nigeria?,” was conducted and written into articles. The objective of this article was to present the work's background, glaucoma overview, research question, rationale, and overview of the work. The work is an ethical (normative) study advocating public-funded glaucoma treatment. Relevant literatures were reviewed and cited. The rationale for the study includes inability of individuals with glaucoma to afford treatment, poor treatment compliance due to poverty, absent universal healthcare insurance, and negative impact of glaucoma on quality life. The work overview includes strong rebuttal of oppositions to public-funded glaucoma treatment; adverse effect of glaucoma on visual function domains, quality of life, daily activities, health, education, economy, and work; three-level budgetary glaucoma funding – macro, meso, and micro-allocations vis–a-vis a justice-based glaucoma funding through a two-tiered healthcare system, namely, tier-one providing basic universal health care for glaucoma at no cost at the point of delivery and tier-two covering all imaginable glaucoma care but at the client's expense are suggested.

Keywords: Glaucoma, glaucoma cost-free treatment, individual with glaucoma, poorly regulated health care, public funding


How to cite this article:
Ayanniyi AA. Should glaucoma be public funded in Nigeria? Background, justification, and the study overview. N Niger J Clin Res 2018;7:1-7

How to cite this URL:
Ayanniyi AA. Should glaucoma be public funded in Nigeria? Background, justification, and the study overview. N Niger J Clin Res [serial online] 2018 [cited 2018 Nov 19];7:1-7. Available from: http://www.mdcan-uath.org/text.asp?2018/7/11/1/235856




  Introduction Top


Glaucoma is a relentless degenerative eye condition of complex origin. It accounts for irreversible blindness and impaired vision in hundreds of thousands of Nigerians, interrupting their capacity to flourish and thereby causing huge economic loss to Nigeria.[1],[2],[3],[4] Glaucoma can be slowed down to enhance life-long useful vision if and only if it is diagnosed in its early stage and effective treatment is sustained.[1],[2],[4] Many individuals with glaucoma (IWG) would not seek or comply with treatment[4],[5] because they could not afford it. Nigeria's current open market (poorly regulated) treatment system is, therefore, inadequate to markedly reduce the burden of glaucoma blindness in Nigeria. The indigent IWG would be relieved with public funding of glaucoma treatment.

The current majorly free market healthcare where Nigerians purchase healthcare, either at the point of use or through insurance schemes would not enhance life-long useful vision. Health charges would deter poor Nigerians from accessing glaucoma care and plausibly worsen their visual outcome. Moreover, free market necessarily exposes IWG to choices that would not maximize health benefit as they would readily fall victims of quacks in eye care services plausibly in an attempt to get cheaper treatment. Such IWG may suffer irreversible visual impairment after long period of inappropriate treatment.[2]

Regrettably, private insurance is even more prohibitive to the indigent because there is an inverse correlation between socioeconomic status and good health.[6] Of note, insurance premiums are based on risk rather than wealth. Therefore, the insurance cost in a free market would necessarily be lowest for the healthiest (usually the richest) and highest for the most sick (usually the poorest).[6] Moreover, private insurance for glaucoma may attract high premium or insurance company may even be reluctant to insure glaucoma because its irreversible blinding nature places it at very high risk for insurance or companies may decide that glaucoma is just uninsurable. Therefore, this fact has put glaucoma in a class of such diseases that always have to be a state-funded safety net[6] to cover the treatment of risks which private insurance companies choose to exclude from their policies.

Nonetheless, a public funding of glaucoma would benefit from government-provided general insurance for all Nigerians because insurance insulates the patient from the real costs of care and would encourage IWG to seek glaucoma treatment than they would in a straightforward free market. This may also have inherent benefit of maximizing the use of healthcare resources and even improve the experience and knowledge of eye care professionals. Finally, there would be gain in administrative cost saved by state-run systems compared with multiple private insurers. A government-driven general insurance coverage would also ensure justice in meeting glaucoma healthcare needs, its sustainability, and would promote (quality) and maximize (quantity) well-being[7] among Nigerian IWG.

Geographical locations where glaucoma treatment is public funded

Notwithstanding its deserved special treatment need, it is a tall order isolating only glaucoma for public funding. This may be so as there are many equally challenging and sometimes life-threatening health conditions that also compete for finite healthcare resources. Moreover, some comorbidity may aggravate glaucoma if left untreated. Therefore, many nations,[8],[9],[10],[11],[12],[13] where citizens' health is given deserved priority, put in place a near-universal health care service, even if citizens pay token as health tax. Of note, such health tax is prepaid and not necessarily at the point of delivery of healthcare service. In such communities,[8],[9],[10],[11],[12],[13] the universal health care necessarily piggybacked the treatment of deserved health conditions including glaucoma. The IWG necessarily fall in with accessing glaucoma treatment and achieving the goal of life-long sight preservation. The government and/or employer bankroll the citizens' health care through health insurance cover.


  Methodology Top


An ethical-based study advocating public-funded glaucoma treatment. The relevant literatures from the library of Keele University, Staffordshire, the United Kingdom, personal library, and online articles were reviewed and cited. This article contains the glaucoma overview, the research question for the large work, and the rationale for the large work. Notwithstanding, an important further section of the article is the overview of a large work which has been divided into articles including arguments against funding glaucoma treatment and rebuttal; harms of glaucoma and arguments for funding glaucoma treatment; and resource allocation and justice arguments for funding glaucoma treatment. These other three articles are in press elsewhere.

Glaucoma overview

Glaucoma is a group of eye diseases with progressive loss of vision, characteristic visual field changes, optic nerve fiber damage with one of the risk factors being raised intraocular pressure (IOP).[1],[2],[14]

Globally, about 64.3 million people, aged 40–80 years have glaucoma, with a projection of 76 million by 2020 and 111.8 million in 2040.[15] Glaucoma is responsible for irreversible blindness in about 4.5 million people worldwide[16] with the majority in Asia and Africa. With a prevalence of 0.7%,[17] over 150 000 Nigerians above age 40 are blinded by glaucoma, and many more are in various stages of visual impairment. Except there are effective glaucoma control measures, more individuals with glaucoma (IWG) risk irreversible blindness.

Glaucoma has many types, but the most common is primary open angle glaucoma (POAG) in which there is no known causative agent; however, many risk factors have been identified including IOP, family history, black race, central cornea thickness, and increasing age.[1],[2],[14],[18] POAG is common among people above 35 years of age. Whereas POAG is common among Nigerians, closed angle glaucoma is common among the Japanese.

Glaucoma has phasic natural history including early phase which is very difficult to detect, middle phase which is detectable with high clinical acumen and investigation, and late phase which is detectable by clinical examination.[2] Glaucoma is a very worrisome eye disease because it causes irreversible damage to optic nerve fibers. However, detection of glaucoma in its early phase and sustained effective treatment can slow down its progression towards preserving useful vision;[19],[20] thus, underscoring the need to screen people particularly those at risk of glaucoma to enhance early detection and treatment toward preserving useful vision in glaucomatous eyes.

Glaucoma is a relentless degenerative eye disease with optic nerve cells at various stages of degeneration. Three categories of nerve cells are therefore possible including dead, dying, and living (normal).[21],[22],[23],[24],[25],[26] The dead nerve cell is irreversible and irreplaceable. The balance of normal and dead nerve cells has implication on visual function; a situation where most or all nerve cells are dead would produce corresponding visual impairment or blindness.[2] Therefore, treatment aims to preserve normal cells, restore normal function in dying cells, and minimize harmful byproducts of dead cells.

Many treatment measures are available for glaucoma including awareness toward early detection, medication, and surgery.[27] Globally, the 2nd week of March (glaucoma week) has been set aside to create awareness on glaucoma. There are basic and sophisticated resources that can detect or diagnose glaucoma. The clinical interventions to control glaucoma include anti-glaucoma drugs[28],[29],[30] and various surgical procedures[31],[32],[33] including laser applications.[1],[2]

There are challenges to successful prevention of glaucoma blindness among Nigerians including low level of glaucoma awareness and education, late presentation,[34] poor treatment compliance,[5] and inadequate yet lopsided glaucoma care resources.[4] Importantly, inability of mostly indigent Nigerian IWG to afford treatment is worrisome and requires an urgent attention to reduce burdensome blindness and visual impairment in the IWG.

Research question

Untreated or poorly treated glaucoma remains a worrisome cause of irreversible blindness among Nigerians. Despite the likelihood of preventing glaucoma blindness by early and sustained treatment, most Nigerians would not have glaucoma treatment because they cannot afford it. However, glaucoma treatment has minimal benefit of marginally improved vision making it less cost-effective and less appreciated by the IWG. Nonetheless, glaucoma treatment is a healthcare need because it can preserve useful vision in the IWG. Comparatively, the price of glaucoma blindness should be much more burdensome to society than the price for marginal visual improvement on glaucoma treatment. Whereas blindness arguably has little if any monetary worth (agreed some individuals are sympathetic and may donate to blind people), marginal visual improvement is priceless. Should glaucoma treatment be public funded in Nigeria?

Rationale for the study

Currently, thousands of Nigerians are either visually impaired or blinded by glaucoma.[1],[2] The trend is regrettable as early and effective treatment can preserve life-long useful vision in the IWG.[28],[29],[30],[31] A major reason for the unfortunate trend and the concern of this work is inability of many IWG to afford glaucoma treatment. This remains a big challenge to sight preservation efforts as countless IWG are not seeking treatment,[2] presenting late for treatment,[35] and complying poorly to treatment including outright dropout from glaucoma care.[5] The rationale for this work is based on observations in eye care practice, Nigerian studies, and Nigeria's healthcare indices.[1],[2],[4],[5],[34],[35]

Observations indicate many IWG cannot afford glaucoma treatment

It has been observed over the years of eye care practice in Nigeria that many IWG cannot genuinely afford glaucoma treatment because they are very poor.[1],[2],[4] Three of such regrettable cases are here presented.

  1. The first case was a middle-aged IWG, male, subsistent farmer, who resided in a remote village. He presented to a Nigerian public eye clinic on account of failing vision. He brought along with him two cockerels for sale and planned to use proceeds to offset his treatment expenses as well as his return fare. He managed to sell one of the cockerels before his arrival in the eye clinic but shockingly discovered that the money was insufficient to pay for the hospital registration
  2. The second was some IWG who came as beneficiaries in a free healthcare program and were requested to follow-up in a public eye clinic. Their response to an enquiry, “do you know the location of the public eye clinic in town?” was quite revealing: “we know there is public eye clinic but we cannot come there, we cannot afford the services there, thank you”
  3. Third, a glaucoma blind man who accompanied his teenage son with bilateral advanced glaucoma into our clinic and declined offered glaucoma surgery on account of inability to afford it. Regrettably, the son served as his father's escort in the street begging vocation.


In an opinion survey of 229 beneficiaries of a cost-free eye care in Nigeria, most participants (57%) indicate reason for attending the program as inability to afford paying eye care services.[36] The proportion may even be higher were only IWG surveyed. The IWG even when aware of their progressive failing vision and available eye care services rarely access eye care for lack of funds. Many IWG are either not gainfully employed or earn less than adequate for their basic life needs.[37]

The health facility or community-based anecdotal observations indicate IWG that cannot afford glaucoma treatments are in three major categories.

  1. First, those who are aware of their progressive failing vision and available eye care resource but cannot access eye care for lack of funds. The IWG in this category are often discovered during free eye screening or eventually find their way to the eye clinic already blind or never bother to visit eye clinic
  2. Second, those that are suspected or diagnosed of having glaucoma during free eye screening but can still cope adequately with the available vision and have a request to be followed up in the eye clinic but cannot access eye care for lack of funds. The IWG in this category often avail themselves with the next available free eye screening. They may present in the eye clinic when it is too late to save any residual vision or may never present in the eye clinic
  3. Third, those that have been diagnosed during routine eye clinic, being on treatment but lost to follow-up for lack of funds to sustain life-long glaucoma treatment. Such IWG often avail themselves of available free eye care or cheap alternative eye care including the traditional eye medication until it is too late to save any residual vision.


Glaucoma can be relentlessly progressive when IWG are not on glaucoma treatment with consequential rapid visual loss. It is possible to reduce or prevent vision loss in IWG with early treatment.[1],[2] However, there is irreversible visual loss while the waiting game lasts without treatment consequent to the inability to afford treatment. A social welfare with public funding of the glaucoma care will save avoidable blindness among Nigerian glaucoma patients.

IWG' poor treatment compliance suggests their inability to afford treatment

In an analysis of 452 dropouts from a follow-up glaucoma clinic in Nigeria, Ashaye and Adeoye[5] report as high as 60.5% dropouts within a year. Notably, 43.1% dropouts occur immediately after the first follow-up eye clinic visit. The study inferred the high dropouts might be due to the IWG perception of glaucoma as being not a serious eye condition. However, the inability of many of the cohort to afford glaucoma treatment should be a major confounder.

This would be so as the high dropouts from a glaucoma clinic particularly after receiving appropriate counseling from eye specialists plausibly suggests inability to afford further treatment by many of such dropouts. This would be much so, as the dropouts include (poor) students, unemployed, retirees, or dependents. In a study, Adekoya et al.[35] report that 27.7% of 177 IWG are retirees. Besides, the high dropouts in the study among the IWG on multiple antiglaucoma eyedrops and those from far distances to the eye clinic would plausibly be due to their inability to afford the cost of glaucoma treatment.

On the other hand, the view that cost adversely affects glaucoma treatment among IWG is probably supported by the study's affirmation that 37.2% of those with severe glaucoma, 40.8% of those who reside nearer the eye clinic, and 52.1% of those on single medication also are dropouts from the follow-up clinic. It appears unreasonable for the IWG to trade-off sight with blindness having been properly informed by the eye specialists the danger of not getting treatment, especially when such IWG can afford treatment. Nonetheless, some IWG may display unusual behavior.

The cost of glaucoma treatment is prohibitive to an average IWG

The cost of treating glaucoma is beyond what an average Nigerian IWG would afford, especially on life-long basis. Glaucoma treatment comprises direct cost particularly for antiglaucoma drugs and surgeries, and indirect costs for associated expenses-tests, transport. In a study among Nigerian IWG, Adio and Onua[37] report a monthly antiglaucoma direct cost of N6 000 (USD 40), and when indirect costs are added, the cost increased to N15 810 (USD 105.4) per IWG. Notably, nearly three-quarters of IWG (73.3%) pay out of pocket for their treatments and two-third (80, 66.7%) visited the eye clinic monthly. Although surgery is believed to be a cheaper option (USD 275.4, N41 310), no IWG opted for it. Undoubtedly, many IWG would neither access nor afford life-long treatment cost in a specialist's eye clinic because they are few and expensive. Adio and Onua[37] conclude “Middle-income earners spent over 50% of their monthly income and low-income earners spend all their monthly earnings on treatment for glaucoma. This situation often resulted in noncompliance with treatment and hospital follow-up visits.”

Nigeria lacks universal health insurance coverage

The membership of National Health Insurance Scheme (NHIS) has been categorized into annual premium paying and exempt group.[38] Most of the current NHIS enrollees are in the exempt group comprising mainly privileged Nigerians who are government or corporate organizations' employees who constitute a small fraction of Nigeria's population. Notwithstanding, the annual premium paying membership provides opportunity for the rest citizens to get enrolled in NHIS. However, its membership registration requires payment of premium and processing fee once yearly.[38] Disturbingly, the pervasive poverty in the community necessarily makes NHIS beyond the reach of the indigents. Further, the general low level of awareness of available NHIS annual premium paying opportunity impacted negatively on the number of NHIS enrollees. Besides, the enrollees have to pay 10% of their treatment fee at delivery, and many times, NHIS treatment is incomplete because required tests or drugs may not be available. Of course, some tests and specific glaucoma treatments are not covered by NHIS. In fact, NHIS benefits package for eye care services is limited and listed as refraction, visual field, scan, keratometry, cataract removal, and eyelid surgery.[39] Furthermore, notwithstanding being enrolled during the working years, pensioners may only access NHIS services under a fresh retirees' exempt. Remarkably, all NHIS ineligible Nigerians and sometimes many NHIS enrollees either pay out of pocket or forgo treatment if they cannot afford it.

Glaucoma lacks sponsors or funders

Unlike cataract treatment that readily attracts funding for being quite cost-effective, glaucoma is notorious for being not attractive to funders or sponsors. Remarkably, the IWG get little or no treatment attention during funded periodic free eye care across Nigeria. Glaucoma is an “orphan” requiring public funding.

Glaucoma is common among working-age group

Glaucoma is a leading cause of visual impairment and blindness among Nigerians, especially the working age group. In a nationwide survey of visual impairment and blindness among Nigerians aged 40 years and above, glaucoma has a prevalence of 0.7% and second only to cataract, the most common cause of blindness, which has a prevalence of 1.8%.[17] It is of note that many Nigeria communities have glaucoma prevalence above a national average of 0.7%. For instance, the prevalence of glaucoma in Nigeria's Sahel savannah and Guinea forest savannah were 1.6, and 0.9%, respectively.[40]

This translates to more than 150,000 blind Nigerians from glaucoma alone. Equally worrisome is the fact that many working-class Nigerians who are at various stages of visual loss from glaucoma may end up being blind. Glaucoma blindness depletes Nigeria's workforce.

Nigeria's healthcare resources are lopsided in cities

Whereas more Nigerians reside in rural than urban areas, there is less health resource in rural than urban areas.[41] This can lead to glaucoma treatment, and eye clinic follow-up noncompliance as many IWG residing in rural areas may not be able to sustain or afford distant journey in accessing lopsided resources for glaucoma care in the urban areas. This essentially translates to added cost (indirect cost) of care considering the transportation, escort, and time loss.

Glaucoma has negative impact on IWG's quality of life

Glaucoma causes blindness among Nigerians with negative impact on the quality of life. Onakoya et al.[42] demonstrate in a study among Nigerian IWG that the quality of life reduces in glaucoma even in its early stage and worsens with the severity of the disease. Overall, glaucoma has a negative impact on the IWG and society.

Eye health professionals' concern

It is an understatement that eye care specialists feel the impact of the inability of IWG to afford treatment of eye conditions, especially glaucoma. This is so in many ways; some IWG present late[1],[2],[4] when little or no medical help can be rendered. This largely left the eye care specialists with no other choice but to communicate distressing news of irreversible blindness to many glaucoma blinds. This is not only depressing to IWG but a psychological trauma to the eye care specialists. Moreover, many IWG are lost to follow-up due to their inability to afford treatment even when they are diagnosed at a stage when treating them can preserve useful vision but only to represent at a later date when no medical help can be rendered. This no doubt rendered the eye care specialists helpless. Furthermore, the eyecare specialists managing IWG who cannot afford the cost of investigation or treatment of glaucoma have hidden loses including lost quality experience while managing IWG or psychological trauma borne out of inability to offer optimal glaucoma care. Much less quality experience is gained over years by eye care specialists managing IWG who cannot comply with management plan on account of prohibitive cost.

The study overview

The work employs relevant empirical and normative studies as well as sound ethical principles to justify why Nigeria should fund glaucoma treatment. It considers arguments against and for a Nigeria nation providing resources to treat its citizens who suffer from glaucoma and holds that funding would be in the overall interest of Nigeria nation.

The work is divided into four articles. This is the first article and concerns itself with the background on glaucoma, the research question, the rationale, and the study overview.

The second article, “Should glaucoma be public funded in Nigeria? Arguments against funding glaucoma treatment and rebuttal” (In press: Nigerian Journal of Ophthalmology) essentially explores the plausible arguments against Nigeria's funding glaucoma treatment from the opponents' perspectives vis-a-vis the necessary rebuttal to the opponents' views. The opponent contends that glaucoma is inherently difficult disease and its treatment has marginal benefit. An opponent is individual (eye health worker or otherwise) whose attitude or practice or action is not supporting public-funded glaucoma treatment. Nonetheless, the complexity of glaucoma should attract public sympathy towards its funding. The opponent considers it unfair for Nigeria to fund glaucoma in the face of other competing, more cost-effective healthcare needs; however, any disease like glaucoma that causes suffering deserve to be treated. Besides, the opponent submits Nigeria lacks adequate healthcare resources to embark and sustain a Nigeria-wide glaucoma treatment, but resources can be mobilized for glaucoma treatment. Furthermore, the Nigerian populace, especially the IWG, is thought not to have glaucoma education or aware of their expected role to make glaucoma treatment a success, but the program will create awareness as it progresses. Importantly, the argument that Nigeria's badly managed economy would not fund glaucoma treatment because of its required huge resources than envisaged is examined.

The third article, “Should glaucoma be Publicly Funded in Arguments for Funding Glaucoma Treatment?” (In press: Nigerian Journal of Ophthalmology), mainly provides arguments for Nigeria's funding glaucoma based on adverse effect of glaucoma blindness. It explores the adverse effects of glaucoma on visual function domains including visual acuity, visual field, color vision, depth perception, and contrast appreciation. It notes correlations between glaucoma visual impairment and diminished quality of life in the IWG. The fact of glaucoma treatment beneficial effects is noted. Furthermore, the implication of glaucoma damaging effects on visual function to the IWG's daily activities, health, education, economy, and work are analyzed. The arguments relate adverse effect of glaucoma to the IWG to its negative impact on society. Importantly, the section notes that public funding glaucoma treatment is social justice and has much economic gain.

Finally, the fourth article, “Should glaucoma be public funded in Nigeria? Resource Allocation and Justice-based Arguments for funding glaucoma treatment” (In press: Nigerian Journal of Ophthalmology) focuses on justice in resource allocation and argues for Nigeria's funding of glaucoma. It observes that glaucoma funding can benefit from healthcare resources allocation at three levels including macroallocations, mesoallocations, and microallocations. It provides justice-based arguments, especially Hippocrates, Marx, Rawls, Aristotle, utilitarianism, egalitarianism, communitarianism, capability theory, well-being theory and fair opportunity rule for Nigeria's funding of glaucoma treatment. These justice-based approaches contend that Nigeria's funding of glaucoma would plausibly enable the IWG to lead a flourishing life and be able to achieve their life goals which blindness caused by glaucoma would have prevented. Moreover, a justice-based healthcare rationing and a two-tiered healthcare system are suggested toward funding glaucoma in Nigeria. While tier-one healthcare provides basic universal healthcare for diseases of public health importance including glaucoma at no cost at the point of delivery, tier-two covers all imaginable glaucoma care but at the IWG's expense. The section observes that Nigeria should provide a general healthcare insurance cover to sustain tier-one. Finally, the section holds that ethical-based rationing in glaucoma treatment would save cost without compromising the best possible visual preservation among the IWG.


  Conclusion Top


Glaucoma is a relentless degenerative eye condition of complex origin. It causes irreversible blindness and impaired vision in many Nigerians interrupting their capacity to flourish leading to huge economic loss to the society. Impaired vision affects available opportunities open to the IWG in life.

Glaucoma can be slowed down enhancing life-long useful vision through early diagnosis and a sustained effective treatment. The treatment can sustain useful vision, appeal to social justice, protect flourishing life, and improve national economy.

It is regrettable countless IWG neither seek nor comply with glaucoma treatment because they cannot afford it. It is of concern the Nigeria's majorly open market treatment cannot markedly reduce burden of glaucoma blindness. However, a public funded glaucoma treatment can improve glaucoma service uptake by IWG. This plausibly translates to lessen burden of glaucoma, social justice and economic gains.

Acknowledgment

This work was part of my dissertation for Master of Arts in Medical Ethics and Law (MA Medical Ethics and Law) at Keele University, Staffordshire, United Kingdom. I acknowledge Dr. Sorcha Ui Chonnachtaigh, my supervisor, for her useful suggestions on this work. I appreciate Tertiary Education Trust Fund (TETFund), Abuja, Nigeria and University of Abuja, Abuja, Nigeria for sponsoring me for Master of Arts in Medical Ethics and Law at Keele University, Keele, Newcastle Under Lyme, Staffordshire, UK. Also, I thank Keele University for its support through Keele International Students Scholarship Award. My special thanks to my family who endured my absence while I was away at Keele University, UK.

Financial support and sponsorship

As in the acknowledgement.

Conflicts of interest

There are no conflicts of interest.



 
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