I was born and raised in Nigeria, a country of 206 million people situated in the heart of West Africa, in its most populated city of Lagos. Nigeria is the richest country in Africa with an annual GDP of approximately $515 billion USD, surpassing South Africa and Egypt as of 2020. Despite its wealth and natural resources, close to 40% of the population lives in extreme poverty at less than $1.90 USD per day. Significant rural-urban disparities exist in education, access to healthcare, and good sanitation. Seeking better opportunities, my mom and sisters immigrated to the United States in 1997 after winning the US visa lottery. We settled in the northern part of Chicago, IL, where I would attend middle school. We didn’t have much at the time, but what I would soon realize is that this opportunity to migrate to the United States would change the trajectory of the rest of my life and offer me a real chance to find myself.
Spending some of my early formative years in Chicago was very eye opening and fueled my interest in reducing health disparities. We initially were uninsured and would seek care at Cook County Hospital in Chicago. Finally, we qualified for Medicaid, which at the time offered us better opportunities to seek healthcare beyond emergency department visits. It was this growing understanding of how social programs impact immigrant communities in the United States that began to fuel my passion for health policy. Close to 20 years later, I had the opportunity as a Barbara Jordan Health Policy Scholar through the Kaiser family foundation to work as a congressional staffer for US Senator Tom Harkin during the early drafting of the Affordable Care Act in 2009. I wrote policy memos on Medicaid, conducted policy research, and represented our office at congressional meetings. I became passionate about the idea of merging an interest in clinical medicine and health policy as the majority of policy decisions regarding healthcare are usually made by individuals who don’t get to understand what it is like to be uninsured or underinsured, or what it is like to make household economic tradeoffs between food, housing, transportation, and health in order to survive. I was determined to bridge this gap in academic medicine and clinical service. Ten years later, there has been no better way to do so than merging a career in global surgery and healthcare policy.
It is estimated that 33% of the global burden of disease is attributed to surgical conditions, yet only in the last 10 years has surgery made it onto the global health agenda with the key publication of the Lancet Commission on Global Surgery’s “Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development.” This landmark publication demonstrated the principles that for far too long a significant number of people worldwide face disparities with seeking access to surgical care. It is estimated that close to 5 billion people, almost two-thirds of the world’s population have no access to surgical and anesthesia care, and 1 out of 4 people would face financial catastrophe as a result of seeking care. At the center of this is healthcare financing, which is an essential and critical component of health systems. In fact, the World Bank estimates that it would be impossible to achieve universal health coverage without spending at least 5% of the GDP on health care, yet many health systems in Sub-Saharan Africa (SSA) spend less than this amount, many patients face financial catastrophe seeking healthcare, and many more people are pushed into poverty on a yearly basis. The Abuja declaration in 2001 brought new promise of a commitment to a minimum of 15% of the countries in the African Union GDP on healthcare, yet most countries in SSA 20 years later have not been able to achieve these targets.
My research over the last 7 years has focused on understanding how countries include surgery in universal health coverage (UHC). In 2014, we conducted a systematic review evaluating the inclusion of surgery in UHC focusing on who is covered, the proportion or cost coverage, and the extent of surgical services provided. We found mentions of surgical conditions across national health plans, the extent of coverage, and financial risk protection were not well defined and, in some cases, limited. In 2014, I had the opportunity to participate in an elective rotation in surgical oncology at Korle-Bu Teaching Hospital in Accra, Ghana. This experience was not only enlightening, exposing me to the challenges of providing surgical care in resource-limited settings, but also fueled my interest in further understanding the Ghanaian National Health Insurance Scheme and its impact in reducing financial barriers to surgical care. In 2017, as part of the NIH-Fogarty Scholars program, I spent a year living in Ghana evaluating the impact of NHIS on out-of-pocket expenditures for general surgical care at Korle-Bu Teaching Hospital. We found that in a cohort of about 200 patients, more that 50% of insured patients risked financial catastrophe seeking surgical care, as out-of-pocket payments were still persistent for anesthesia fees, medicines, supplies, laboratory testing, and ancillary services that were in theory covered by the scheme. This led to several presentations at the Ghana College of Physicians and Surgeons, the National Health Insurance Authority, as well as at the West African College of Surgeon’s Conference. The reality is that sometimes there is a disconnect between the policy-makers and the experience of patients with insurance. Lack of price transparency, mistrust in the system, supply chain shortages, and misallocation of funds contribute to the disparities we see in gaps in coverage. A coordinated effort between the ministries of finance (MOF) and ministry of health (MOH) is key to a sustaining the mission of national health insurance schemes. In some instances, only 50% of the funds allocated by MOF actually is received by the MOH to provide much needed health services. Critical understanding of the dimensions of coverage in addition to how funds flow through a health system is crucial to developing recommendations for improving healthcare financing for surgery.
Findings from our study on financial catastrophe in seeking care weren’t unique to surgical care. In a systematic review of the 14 years of Ghana with NHIS we also found up to 18% of patients risking financial catastrophe as a result of seeking care for a variety of non-surgical conditions such as malaria and antenatal care. This article was significant because a majority of studies of this nature were conducted in economically deprived parts of Ghana. Sub-Saharan Africa is home to 90% of the world’s population of people living in extreme poverty. Poverty is associated with lower life expectancy, lack of protection against common disease threats, unemployment, and even death. When you look across Sub-Saharan Africa, in a review of four studies, close to 60% to 90% of patients seeking surgical care risk financial catastrophe due to out-of-pocket spending. A scoping review of 149 articles on a situational analysis of healthcare financing for surgery and anesthesia still found significant gaps in budgetary allocations to surgery on a national level six years since LCOGs, despite much generated political will to adopt NSOAPs amongst countries. Critical to this is how the poor access healthcare. What is the extent of financial risk protection provided by insurance schemes across the continent or in ‘’free care”? What is the provider-payer mechanism, and is it regressive for the poor? How do we identify the poor via means testing, and are there social services available at the point of care to reduce the risk of needing to borrow, liquidate assets, or fall further in debt as a result of seeking care? These questions are key to understanding how we as a global community protect the poor from further poverty. With the global pandemic at hand and many resources currently being diverted toward it, many countries will now have to rebuild their infrastructure to also to address the growing burden of diseases, including non-communicable diseases that continue to be on the rise.
The growing burden of NCDs in SSA has prompted much needed national plans in cancer control across the continent. As a budding surgical oncologist, I have had the opportunity to really explore the inclusion of global cancer oncology on the global health agenda. In 2019, the NCCN published low-to-middle-income country (LMIC) guidelines to try to address the growing need to define operative standards for managing close to 90% of cancers seen in LMICs. These guidelines are stratified based on level of resources available (i.e., basic, core, and enhanced resources), though clinical trial data to guide evidence-based decision making is limited to extrapolation from clinical trials conducted in high-income countries given the limited number of practices changing clinical trials conducted in Sub-Saharan Africa.
In addition, the Lancet Commission on Global Cancer Oncology published a set of recommendations calling for the urgent need for global cancer surgery, as 80% of all cancers require surgical intervention yet less than 25% of the world’s population has access to that treatment. Over the last two years, I have had an opportunity to be involved in cancer control efforts in Nigeria, my birth country. Nigeria has 9 comprehensive cancer centers, 8 public and one private center known as Lake-Shore Cancer Center. Lake-Shore was founded as a bilateral partnership between Roswell Park Cancer Center in Buffalo, NY, and Lakeshore as a way of bringing world-class cancer care to patients in need. They offer a variety of services, including chemotherapy, surgery, endocrine therapy, and radiation through Lagos State Teaching Hospital for colorectal, breast, and prostate cancer, amongst others. Through the pandemic, I have been involved in participating in the multi-disciplinary tumor board joint discussions on cancer care. This has been quite rewarding over the last two years and has given me a new perspective on the growing need for multidisciplinary teams globally. I find the opportunity to offer standard of care and to leave no cancer patient behind rewarding. I look forward to a growing community of academic surgical oncologists interested in filling the gaps in global cancer care worldwide.
References
Okoroh JS, Chia V, Oliver EA, Dharmawardene M, Riviello R. Strengthening Health Systems of Developing Countries: Inclusion of Surgery in Universal Health Coverage. World J Surg. 2015 Aug;39(8):1867-1874. doi: 10.1007/s00268-015-3031-7. PMID: 25802236.
Okoroh J, Sarpong DO, Essoun S, Riviello R, Harris H, Weissman JS. Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana's National Health Insurance Scheme at Korle-Bu teaching Hospital. BMC Health Serv Res. 2020 Jan 17;20(1):45. doi: 10.1186/s12913-020-4887-2. PMID: 31952520; PMCID: PMC6969414.
Okoroh J, Essoun S, Seddoh A, Harris H, Weissman JS, Dsane-Selby L, Riviello R. Evaluating the impact of the national health insurance scheme of Ghana on out of pocket expenditures: a systematic review. BMC Health Serv Res. 2018 Jun 7;18(1):426. doi: 10.1186/s12913-018-3249-9. PMID: 29879978; PMCID: PMC5992790.
Okoroh JS, Riviello R. Challenges in healthcare financing for surgery in sub-Saharan Africa. Pan Afr Med J. 2021 Feb 22;38:198. doi: 10.11604/pamj.2021.38.198.27115. PMID: 33995804; PMCID: PMC8106793.
Ifeanyichi M, Aune E, Shrime M, Gajewski J, Pittalis C, Kachimba J, et al. Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review. BMJ Open. 2021 Oct 19;11(10):e051617. doi: 10.1136/bmjopen-2021-051617. PMID: 34667008; PMCID: PMC8527159.
Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015 Aug 8;386(9993):569-624. doi: 10.1016/S0140-6736(15)60160-X. Epub 2015 Apr 26. PMID: 25924834.
