1. DESCRIPTIVE ANALYSIS OF CARDIAC SERVICES IN URBAN NIGERIA Tolu Amune, BSc; Enoma Alade,BDS,DDS,MPH; Arash Farzan, BS Anadach Group, Lagos, Nigeria ABSTRACT Objective: The purpose of this study is to analyze the cardiology market in urban Nigeria—to provide an in-depth understanding of the cardiac epidemiologic landscape and payor/provider regulatory dynamics, and develop strategies to meet the growing effective demand for cardiac services in Nigeria. Method: A cross-sectional survey was administered to 66 Nigerian physicians (including 20 Cardiologists) in both the public and private sectors, 19 C-suite executives from top healthcare organizations, and 108 prospective Nigerian patients to assess both quantitatively and qualitatively the availability, cost, and quality of cardiac services in Nigeria and health insurance provisions. Analysis of the cardiac market was performed to understand the effective demand and market potential for cardiac services in urban Nigeria. Results: The clinical burden of cardiac disease in Nigeria is growing due to increased population risk factors of smoking, alcohol consumption, obesity, stress, poor diet. 80% of physicians interviewed stated that the incidences of cardiovascular services (CVD) within their practices are on the rise. They also stated the most prevalent cardiac disease states were Hypertension, Ischemic Heart Disease, Chronic Heart failure and Valvular Heart Disease. Patient responses revealed that many have a negative perception of the quality of care of cardiac services in Nigeria. Analysis of the market illustrated the potential effective demand for cardiac services to between 2.4 and 3.2 million people. Conclusion: The CVD burden in Nigeria is expanding at a significant rate due to the prevalence of associated risk factors. Provision of cardiology services is currently underdeveloped, thus creating a demand for quality healthcare which spurs patients, who can afford it, abroad for effective care (mostly to India). Only by focusing on increased preventive programs e.g. reducing smoking and other risk factors, restructuring insurance and provider policy to cover a greater breadth of cardiac services and procedures and expanding national cardiac facilities and training programs will Nigeria be able meet the effective demand for cardiac services. BACKGROUND The westernization of Nigeria has had a significant impact on the growing incidence of CVD in the country. Changes in lifestyle trends show an increase in smoking, alcohol consumption, obesity, stress, and poor diet across the population—major factors that increase risk of CVD (Figure 1). Figure 1: Clustering of CVD and NCD risk factors in Nigerian Population according to Ezenwaka et al, 1997 Atherosclerosis Article. The availability of cardiac services in Nigeria is not sufficient to match the growing rate of CVD in the country There is a critical shortage in the number of trained cardiologists There are only 100 trained cardiologists, of which there is 1 interventional cardiologist, 1 nuclear cardiologist, less than 30 echocardiography specialists, and no electro physiologists. Furthermore, we estimate there are at least 50 cardiologists and cardio thoracic surgeons of Nigerian origin in the US. The Nigerian healthcare system is structured such that a majority of Nigerians (97%) pay out of pocket for medical expenses. 1 Only 3% of Nigerians are insured under the Nigerian Health Insurance Scheme (NHIS). 1 The current insurance provider landscape is fragmented, providing mostly basic cardiac services, despite a growing demand for more complicated services which are presently obtained at international referral locations. RESULTS Figure 3: Diagnosis of Hypertension is on the Rise, Obesity is a growing problem in Nigeria especially in patients from higher socio-economic classes. 2 The physicians views are supported by research and survey data indicating that the cardiac burden in Nigeria is continuing to grow. 2 Figure 4: Patient Survey Responses for Preference of Treatment and Reasoning Majority of patients (70%) prefer treatment by a cardiologist despite the short supply Reasons for preference include: financial, better care, cultural and close proximity to care In Nigeria, majority of cardiac services are provided by teaching and government hospitals: Figure 5: Market share of cardiology services, % in Nigeria Figure 6: Effective Demand for Cardiac Services in Abuja and Lagos Analysis of the cardiac market estimates the effective demand for the Nigerian market to be between 2.4 to 3.2 million people. 3 MATERIALS AND METHODS Figure 2: Qualitative and Quantative Data Gathering Process: Survey administered to spectrum of physicians, cardiologists, healthcare policy makers, and patients. REFERRAL SYSTEMS Figure 7: Referral Flow for Patients Who are Uninsured is Unstructured and Fragmented The market is fragmented and underserved despite a demonstrated willingness of patients to go abroad to receive the more complex services they desire. Thus there is a compelling demand for niche provider of complex cardiac services in Nigeria reinforced by widening health insurance coverage. Figure 8: Referral Flow for Insured Patients is Well Structured but Underdeveloped The middle to upper income class in Nigeria has grown significantly over the last decade and is continuing to grow. The willingness of these segments of the population to pay for quality healthcare is motivating trends for health tourism and to seek care abroad in countries like South Africa and India. The 23 health insurance companies and the NHIS cover only 3% of the Nigerian population. An increase in provider services to cover more complex services and expansion of domestic cardiac infrastructure may reduce health tourism out of Nigeria. CONCLUSION The CVD burden in Nigeria is expanding at a significant rate due to the prevalence of associated risk factors. Provision of cardiology services is currently underdeveloped creating a demand for quality healthcare which spurs patients, who can afford it, abroad for effective care (mostly to India). Only by focusing on increased preventive programs e.g. reducing smoking and other risk factors, restructuring insurance and provider policy to cover a greater breadth of cardiac services and procedures and expanding national cardiac facilities and training programs will Nigeria be able meet the effective demand for cardiac services. This is very important as cardiac disease often hits the major financial provider within a family (in an environment with high dependency ratios) at the height of their earning powers. NOTES 1. National Health Accounts of Nigeria, 1998-2002 by Adedoyin Soyibo, Final Report submitted to World Health Organization, Geneva. 2. Reports from Nigerian Heart Foundation; Federal Ministry of Health and Social Services submitted to WHO database. The prevalence of hypertension in seven populations of West African origin; Cooper et al, American Journal of Public Health, 1994) 3. Top Down Approach Assumptions: Using the India Cardiologist Workforce of 3 Cardiologists per one million because this is the most comparable to Nigeria 4. Manpower in Cardiology in Europe by P.Block,M.C.Perch and J.P. Letouzey: European Heart Journal (2000) 21, 1135–1140 doi:10.1053/euhj.1999.1935, available online at http://www.idealibrary.com 5. Other sources: Interviews, team analysis, British Cardiac Society, UEMS –CS manpower survey CONTACT: EMAIL ADDRESS:info@anadach.com The responses of physicians revealed that 80% of them feel the incidence of CVD is increasing and stated that “the sedentary and stressful lifestyles in the urban areas are major contributory factors” and that “there are too many cases and too few cardiologists with limited resources.”